Traditional Approach:
Categories
Nov 1, 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
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
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.
May 1, 2020
Pediatric Readiness is not just an ideal -- it's a tangible plan, a toolkit, and even better, an attitude
How to improve your institution, and your own personal pediatric readiness.
Feb 1, 2020
Lund and Browder Chart to Estimate Burn Size in Children
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"
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.
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:
- Consistently under 2nd percentile in weight over time
- "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:
- Not enough offered
- Not enough taken
- 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.
For Older Children, Adolescents, and Adults (8 or greater) -- START:
For Children less than 8 years of age (Infants Use Pediatric Assessment Triangle) -- JumpSTART:
MCI Organizational Chart
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.
©2016 Tim Horeczko