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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: Page 2
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.

 
 
This image has an empty alt attribute; its file name is mass-casualty-mockups.jpg
 
An MCI drill
 
 

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

 
 
This image has an empty alt attribute; its file name is StartAdultTriageAlgorithm.gif
 
 
 

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

 
 
This image has an empty alt attribute; its file name is JumpStartPediatricTriageAlgorithm.gif
 
 
 
 
 
 

 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

Oct 1, 2018

PEMplaybook.org

Sep 1, 2018

PEMplaybook.org

Aug 1, 2018

Does Your Patient Have Streptococcal Pharyngitis?

No Problem -- I'll just Swab.

Not So Fast...

 

Fagan Nomogram for Likelihood Ratios

1. Decide on your pre-test probability of the disease (choose an approximate probability based on our assessment)
2. Use the likelihood ratio that correlates to your exam.
3. Draw a straight line frm your pre-test probability starting point, to the LR of the feauture/test, take it through to find your post-test probability
4. Use this new post-test probability to help in your decision


Your patient has palatal petechiae, which confers a positive likelihood ratio (LR+) of 2.7
See below how to use this statistic based on your clinical assessment"

Low Probability

Moderate Probability

High Probability

 

List of Likelihood Ratios for Streptococcal Pharyngitis

Symptoms and signs

Positive LR (95% CI)

Negative LR (95% CI)

Sensitivity (95% CI)

Specificity (95% CI)

Scarlatiniform rash

3.91 (2.00-7.62)

0.94 (0.90-0.97)

0.08 (0.05-0.14)

0.98 (0.95-0.99)

Palatal petechiae

2.69 (1.92-3.77)

0.90 (0.86-0.94)

0.15 (0.10-0.21)

0.95 (0.91-0.97)

Chills

2.16 (0.94-4.96)

0.88 (0.79-0.98)

0.21 (0.18-0.24)

0.90 (0.83-0.97)

Anorexia

1.98 (0.83-4.75)

0.53 (0.26-1.10)

0.62 (0.12-1.11)

0.62 (0.12-1.12)

Pharyngeal exudate

1.85 (1.58-2.16)

0.78 (0.74-0.82)

0.38 (0.32-0.44)

0.79 (0.73-0.84)

Vomiting

1.79 (1.56-2.06)

0.85 (0.81-0.90)

0.28 (0.21-0.36)

0.84 (0.79-0.89)

Tender cervical nodes

1.72 (1.54-1.93)

0.78 (0.75-0.81)

0.40 (0.35-0.46)

0.77 (0.71-0.82)

Sibling with sore throat

1.71 (0.82-3.53)

0.92 (0.82-1.03)

0.18 (0.14-0.23)

0.89 (0.83-0.94)

Halitosis

1.54 (0.79-2.99)

0.95 (0.81-1.12)

0.12 (0.05-0.29)

0.92 (0.86-0.99)

Tonsillar and/or pharyngeal exudate

1.40 (1.10-1.77)

0.86 (0.75-0.98)

0.37 (0.28-0.46)

0.74 (0.68-0.78)

Large cervical nodes

1.39 (1.16-1.67)

0.67 (0.53-0.84)

0.64 (0.50-0.76)

0.54 (0.41-0.67)

Lack of cough

1.36 (1.18-1.56)

0.59 (0.48-0.73)

0.73 (0.66-0.78)

0.46 (0.38-0.55)

Tonsillar exudates

1.35 (0.98-1.87)

0.81 (0.63-1.06)

0.46 (0.27-0.67)

0.66 (0.48-0.80)

Tonsillar swelling

1.27 (1.04-1.54)

0.67 (0.52-0.85)

0.70 (0.64-0.76)

0.44 (0.32-0.57)

Dysphagia

1.22 (1.00-1.48)

0.68 (0.51-0.91)

0.72 (0.55-0.85)

0.41 (0.23-0.62)

Headache

1.22 (0.95-1.57)

0.90 (0.77-1.04)

0.39 (0.28-0.51)

0.68 (0.58-0.76)

Lack of coryza

1.21 (1.08-1.35)

0.69 (0.55-0.88)

0.72 (0.64-0.79)

0.40 (0.34-0.48)

Abdominal pain

1.18 (0.92-1.51)

0.95 (0.89-1.03)

0.24 (0.19-0.30)

0.79 (0.75-0.83)

Red tonsils and/or pharynx

1.13 (0.96-1.33)

0.41 (0.16-1.02)

0.93 (0.85-0.96)

0.18 (0.09-0.35)

Reported fever

1.07 (0.96-1.19)

0.86 (0.67-1.11)

0.71 (0.58-0.82)

0.33 (0.23-0.49)

Red tonsils

1.07 (0.86-1.34)

0.82 (0.40-1.69)

0.80 (0.60-1.00)

0.25 (0.00-0.51)

Red pharynx

1.06 (0.95-1.18)

0.56 (0.27-1.17)

0.93 (0.81-0.98)

0.12 (0.03-0.34)

Documented temperature >38° or >38.5°C

1.02 (0.87-1.21)

0.98 (0.83-1.15)

0.50 (0.36-0.63)

0.51 (0.38-0.65)

Summer

0.86 (0.61-1.20)

1.02 (1.00-1.05)

0.13 (0.00-0.33)

0.85 (0.65-1.04)

Arthralgia

0.74 (0.18-3.08)

1.02 (0.97-1.06)

0.09 (0.00-0.25)

0.90 (0.77-1.04)

Conjunctivitis

0.73 (0.46-1.16)

1.02 (0.98-1.05)

0.05 (0.02-0.11)

0.94 (0.85-0.98)

Acute otitis media

0.65 (0.14-2.91)

1.04 (0.93-1.16)

0.03 (0.01-0.05)

0.94 (0.84-1.04)

History of tonsillectomy

0.64 (0.49-0.84)

1.07 (1.03-1.11)

0.11 (0.08-0.13)

0.84 (0.81-0.86)

Hoarseness

0.62 (0.46-0.83)

1.04 (1.03-1.06)

0.06 (0.03-0.12)

0.90 (0.85-0.93)

Diarrhea

0.51 (0.33-0.79)

1.04 (0.99-1.11)

0.03 (0.00-0.06)

0.93 (0.86

Modified from: Shaikh et al. 2012

This post and podcast are dedicated to Sarah Werner for her constant encouragement of the story in all of us.  Check out Write Now with Sarah Werner.

Selected References

Cheung L et al. Throat swab have no influence on the management of patients with sore throats. J Laryngol. 217; 131:977-981.
Ebell MH et al. Rational Clinical Examination: Does This Patient Have Streptococcal Pharyngitis? JAMA. 2000;284(22):2912-2918
Homme JH et al. Duration of Group A Streptococcus PCR positivity following antibiotic treatment of pharyngitis. Diagn Microbiol Infect Dis. 2018 Feb;90(2):105-108.
Nakhoul GN et al. Management of Adults with Acute Streptococcal Pharyngitis: Minimal Value for Backup Strep Testing and Overuse of Antibiotics. J Gen Intern Med. 2013 Jun; 28(6): 830–834.
Oliver J et al. Group A Streptococcus pharyngitis and pharyngeal carriage: A meta-analysis. PLoS Negl Trop Dis. 2018 Mar 19;12(3):e0006335.
Shaikh N, Leonard E, Martin JM. Prevalence of streptococcal pharyngitis and streptococcal carriage in children: a meta-analysis. Pediatrics. 2010 Sep;126(3):e557-64.
Shaikh et al. Accuracy and Precision of the Signs and Symptoms of Streptococcal Pharyngitis in Children: A Systematic Review. J Pediatrics. 2012; 3:487-493.e3

Jul 1, 2018

How do we make the diagnosis?

What now?

 

Concussion in Sport Group Guidelines

Concussion Recognition Tool (for coaches, trainers on field)

Child Sports Concussion Assessment Tool, 5th Ed. (Child SCAT); Ages 5-12

Sports Concussion Assessment Tool, 5th Ed. (SCAT5); Ages 13 and Up

This post and podcast are dedicated to the great K Kay Moody, DO, MPH for her stalwart effort to care for both patient and doctor. Thank you for all that you do to help us to be our best and for promoting #FOAMed #FOAMped and #MedEd.

References

Churchill NW et al. The first week after concussion: Blood flow, brain function and white matter microstructure. Neuroimage Clin. 2017; 14: 480–489.
Ellis MJ et al. Psychiatric outcomes after pediatric sports-related concussion. J Neurosurg Pediatr. 2015; 16:709-718.
Graham R et al. and the Committee on Sports-Related Concussions in Youth; Board on Children, Youth, and Families; Institute of Medicine; National Research Council. Sports-Related Concussions in Youth: Improving the Science, Changing the Culture. Washington (DC): National Academies Press (US); 2014 Feb 4.
Harmon KG et al. American Medical Society for Sports Medicine position statement: concussion in sport. Br J Sports Med. 2013; 47:15-26.
McCrory P et al. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. Br J Sports Med. 2016
Purcell LK et al. What factors must be considered in “return to school” following concussion and what strategies or accommodations should be followed? Br J Sports Med. 2018; 0:1-15.
Wang KK et al. An update on diagnostic and prognostic biomarkers for traumatic brain injury. Exp Rev Molec Gen. 2018; 18(2):165-180.
Wang Y et al. Cerebral Blood Flow Alterations in Acute Sport-Related Concussion. J Neurotrauma. 2016 Jul 1; 33(13): 1227–1236.

Jun 1, 2018

PEMplaybook.org

May 1, 2018

PEMplaybook.org

Apr 1, 2018

 

References

Baracco R et al. Pediatric Hypertensive Emergencies. Curr Hypertens Rep. 2014; 16:456.

Belsha CW. Pediatric Hypertension in the Emergency Department. Ann Emerg Med. 2008; 51(3):21-24.

Chandar J et al. Hypertensive crisis in children. Pediatr Nephrol. 2012; 27:741-751.

Dionne JM et al. Hypertension Canada’s 2017 Guidelines for the Diagnosis, Assessment, Prevention, and Treatment of Pediatric Hypertension. Canadian J Cardiol. 2017; 33:577-585

*Flynn JT, Kaelber DC, Baker-Smith CM, et al; SUBCOMMITTEE ON SCREENING AND MANAGEMENT OF HIGH BLOOD PRESSURE IN CHILDREN. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017; 140(3):e20171904

Gilhotra Y et al. Blood pressure measurements on children in the emergency department. Emergency Medicine Australasia. 2006; 18:148-154.

Lurbe E et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and adolescents. J Hypertens. 2016; 34:1-35.

Patel NH et al. Evaluation and management of pediatric hypertensive crises: hypertensive urgency and hypertensive emergencies. Open Access Emergency Medicine. 2012; 4:85-92.

Yang WC et al. Clinical Analysis of Hypertension in Children Admitted to the Emergency Department. Pediatr Neonatol. 2010; 1:44-51.

 

Addendum: Causes of Malignant Hypertension by Age

Infant to Toddler Preschool to School Age Adolescent to Adult
Renal disease Renal disease Primary hypertension
Coarctation of the aorta Coarctation of the aorta Medication non-adherence
Bronchopulmonary dysplasia Drug induced/toxicologic Renal disease
Increased intracranial pressure Increased intracranial pressure Increased intracranial pressure
Volume overload Pheochromocytoma Pheochromocytoma
Congenital adrenal hyperplasia Primary hypertension Drug induced/toxicologic

Adapted from: Constantine E. Hypertension. In: Textbook of Pediatric Emergency Medicine, 6th Ed. Fleischer GR, Ludwig S, Henretig FM (Eds). Lippincott, Williams & Wilkins, Philadelphia. 2010; p315.

 

This post and podcast are dedicated to Manpreet 'Manny' Singh for his collegiality, collaboration, and overall awesomeness. 

Mar 1, 2018

A Social Visit or Your Most Dangerous Presentation Tonight?

[Details in Audio]

This post and podcast are dedicated to Henry Goldstein, B.Pharm, MBBS for his tireless dedication to all things #FOAMed, #FOAMped, and #MedEd.  You are awesome.  Make sure to visit Don't Forget the Bubbles!

References

Cohen GM, Albertini LW. Colic. Pediatr Rev. 2012; 33(7):332-3.

Friedman SB et al. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics. 2009; 123(3):841-8

Herman M, Le A. The crying infant. Emerg Med Clin North Am. 2007 Nov;25(4):1137-59.

Poole SR. The infant with acute, unexplained, excessive crying. Pediatrics. 1991; 88 (3): 450-5.

Prentiss KA, Dorfman DH. Pediatric Opthalmology in the Emergency Department. Emerg. Med. Clin. N. Am. 2008; 26: 181-198.

Shope TR, Rieg TS, Kathiria NN. Corneal abrasions in young infants. Pediatrics. 2010 Mar;125(3):e565-9. Epub 2010 Feb 8.

Feb 1, 2018

You know how to intubate safely.  You can recite all of the Ps backwards and forwards.

Until you can't.

Real-time trouble-shooting.

[Details in Audio]


This post and podcast are dedicated to Mads Astvad for sharing his enthusiasm, clinical excellence, and #FOAMed warrior spirit.

Tak, min ven!  #SMACConia #Vikingeblod

Jan 1, 2018

Ovarian torsion is like the MI of the pelvis.  Sometimes all it takes is a good story to investigate.

When to worry, when to walk it off, and when to work it up:

 

 

What is the typical presentation of ovarian torsion?

There is none.  The presentation varies so much, we need a rule to live by:

Unilateral pelvic pain in a girl is ovarian torsion until proven otherwise.  This includes the cases in which you are concerned about appendicitis.  They both can be fake-outs.

Often the pain is severe and abrupt, but trying to tease this out is often not fruitful.

Here are the often-reported signs and symptoms associated with ovarian torsion:

Stabbing pain, 70%

Nausea and vomiting, 70%

Sudden, sharp pain in the lower abdomen, 59%

Pain radiating to the back, flank, or groin, 51%

Peritoneal signs, 3%

Fever, less than 2%

And of course…no pain on presentation…30%...intermittent torsion.

What is the mechanism of ovarian torsion?

  1. Structurally abnormal ovary (including cysts) that causes the ovary to flop over and twist on its vascular axis
  2. Hypermobile ovary with vigorous movement twists on its vascular pedicle and cuts off blood supply

The Dual Blood Supply to the Ovaries: Why Doppler Flow can Fool You

What ultrasound findings suggest ovarian torsion?

  1. The enlarged hyper or hypoechoic ovary from generalized edema
  2. Peripherally displaced follicles with hyperechoic central stroma – this is called the string of pearls sign, because the stroma is edematous, leaving the follicles to stand out
  3. A midline ovary – if the ovary magically makes it to midline, something is up
  4. Free fluid in the pelvis – this is seen in the vast majority of cases

As far as Doppler flow goes, you may see one of several scenarios:

  1. Little or no venous flow – this is very common, as we talked about, because the low pressure venous system is the first to take a hit in torsion
  2. Totally absent arterial flow – this is not as common, but totally diagnostic
  3. There may be no flow in diastole, or the flow may even be reversed. Rememver the red and blue of dopple does not correspond to arterial and venous.  Doppler is a vector.  Red is fluid coming towards the probe, blue is programmed to present flow away from the probe.  If you have just one or the other, then by definition there is a problem with the vascular circuit.

Other things you may see on ultrasound include focal tenderness with the probe, or the whirlpool sign – this is a twisted vascular pedicle.  

In children, is there an ovarian size (volume) that rules out torsion?”

In the Journal of Pediatric Radiology, Servaes et al catalogued the ultrasound findings in children with surgically confirmed torsion over a 12 year period.  In this case series of 41 patients, the median age was 11.  The age range was one month old to 21 years of age.  They found that in torsed ovaries, the ovarian volume was 12 x that compared to the normal, non-torsed contralateral ovary.

That is to say, in this case series all torsed ovaries were larger than the normal contralateral ovary.

 

Summary

Sudden unilateral lower abdominal or pelvic pain in a female? Think torsion.

Have a low threshold for investigation.

Know the performance characteristics of ultrasound findings and involve a gynecologist early.

 

This post and podcast are dedicated to Stephanie Doniger, MD for her enthusiasm, spirit, and expertise in #MedEd #FOAMed #FOAMped #POCUS 

 
References

Abe M, Sarihan H. Oophoropexy in children with ovarian torsion. Eur. J. Pediatr. Surg. 2004;14:168.

Aziz D, Davis V, Allen L, Langer J. Ovarian torsion in children: Is oophorectomy necessary? J. Pediatr. Surg. 2004;39:750-3.

Bristow RE, Nugent AC, Zahurak ML, et al. Impact of surgeon specialty on ovarian-conserving surgery in young females with an adnexal mass. J. Adolesc. Health 2006;39:411.

Chang YJ, Yan DC, Kong MS, et al. Adnexal torsion in children. Pediatr. Emerg. Care. 2008;24:534-7.

Conforti A, Giorlandino C, Bagolan P. Fetal ovarian cysts management and ovarian prognosis: a report of 82 cases. J. Pediatr. Surg. 2009;44:868; author reply 868-9.

Guthrie BD, Adler MD, Powell EC. Incidence and trends of pediatric ovarian torsion hospitalizations in the United States, 2000-2006. Pediatrics 2010;125:532-8. Epub 2010 Feb 1.

Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann. Emerg. Med. 2001;38:156-9.

Huang TY, Lau BH, Lin LW, Wang TL, Chong CF, Chen CC. Ovarian cyst torsion in a toddler. Am. J. Emerg. Med. 2009;27:632, e1-3.

Hurh PJ, Meyer JS, Shaaban A. Ultrasound of a torsed ovary: characteristic gray-scale appearance despite normal arterial and venous flow on Doppler. Pediatr. Radiol. 2002;32:586-8. Epub 2002 May 25.

Kokoska E, Keller M, Weber T. Acute ovarian torsion in children. Am. J. Surg. 2000;180:462-5.

Oltmann SC, Fischer A, Barber R, Huang R, Hicks B, Garcia N. Cannot exclude torsion – a 15-year review. J. Pediatr. Surg. 2009;44:1212-6; discussion 1217.

Chmitt ER et al. Twist and Shout! Pediatric Ovarian Torsion Clinical Update and Case Discussion. Pediatr Emerg Care. 2013; 29(4):518-523.

Servaes S, Zurakowski D, Laufer MR, Feins N, Chow JS. Sonographic findings of ovarian torsion in children. Pediatr. Radiol. 2007;37:446-51. Epub 2007 Mar 15.

Valsky DV. Added value of the gray-scale whirlpool sign in the diagnosis of adnexal torsion. Ultrasound Obstet. Gynecol. 2010;36:630-4.

Dec 1, 2017

Dogma often dictates routine care.

There are times when we have to attend to paradigm shifts.

An easy way to save lives?  Just say no to (these) drugs:


Codeine

Normally metabolized into codeine-6-glucuronide (50-70%) and norcodeine (10-15%).  Codeine, codeine-6-glucuronide, and norcodeine have low affinity for the μ (mu) receptor.

However, the most active metabolite of codeine is morphine with 200x the affinity for the mu receptor as the codeine derivates.  The problem is, people vary in its metabolism from 0-15% of codeine is metabolized to morphine.

Ok, codeine is lame at best, unpredictable at worst.

True.  Unless you are hiding a genetic time bomb.

You're an ultra-rapid metabolizer.

Some people have multiple extra copies of the DNA sequence for the CYP2D6 enzyme.  Ultra rapid metabolizers funnel a huge proportion of their codeine into morphine metabolism, resulting in a bolus of morphine, ending in apnea.

Promethazine with codeine

This combination is no better than placebo -- all of the risks, with no proven benefit.  This combination is notoriously abused -- as purple drank or sizzurp.  The rapper Pimp C died of this.

Speaking of cough syrups...

The AAP recommends no cough and cold preparations in children under age 6.  They have not been adequately studied in young children, and are not recommended for treating the common cold.

What then?  You gotta give me something, doctor!

Ok, Honey!

In a study in the Archives of Pediatric and Adolescent Medicine, Dr Paul and colleagues published: Effect of honey, dextromethorphan, and no treatment on nocturnal cough and sleep quality for coughing children and their parents.  They compared a buckwheat honey, honey-flavored dextromethorphan (DM) and no treatment 30 min before bed for children with upper respiratory tract infections.

Of the three, honey, dextromethorphan, and no treatment – honey scored the best for symptom improvement and cough frequency.

Over age 1?  Cough and cold?  Honey.  There is no concern about accidental overdose, parents are doing something with a proven effect, and compliance is pretty much 100% -- and Grandma approves.

Dextromethorphan

No proven benefit over placebo.  Also widely abused, in pill form ("Skittles") and/or liquid form mixed in alcoholic beverage ("robotripping").

Alternatives to Codeine

Details in Audio:

Morphine liquid

Acetaminophen and Hydrocodone

 

PEARLS AND PITFALLS IN PEDIATRIC PAIN

Allow the child to speak for himself whenever possible. After acknowledging the parent’s input, perhaps try “I want to make sure I understand how the pain is for you. Tell me more.”

Engage parents and communicate the plan to them. Elicit their expectations, and give them of preview of what to expect in the ED.

Opioids are meant for pain caused by acute tissue injury, for the briefest period of time feasible. Older school-aged children and adolescents are increasingly at risk for opioid dependence and addiction.

Give detailed advice on how to manage pain at home. Set expectations. Let them know you understand and will help them through your good advice that will carry them through this difficult time. Patients and families often just need a plan. Map it out clearly.

And...

Just say no to: codeine, promethazine with codeine, and dextramethorphan.

Selected References

Dhaliwal G, Hsu D. Tramadol Ultra Rapid Metabolizers at Risk for Respiratory Depression. Pain Physician. 2016; 19(2):E361.

European Medicines Agency. Restriction on the use of codeine for pain relief in children—CMDh endorses PRAC recommendation [press release]. June 28, 2013.

FDA. Most Young Children With a Cough or Cold Don't Need Medicine.

Hartling L et al. How Safe Are Common Analgesics for the Treatment of Acute Pain for Children? A Systematic Review. Pain Res Manag. 2016; 2016: 5346819.

Grond S, Sablotzki A. Clinical pharmacology of tramadol. Clin Pharmacokinet. 2004;43(13):879-923.

Jin J. Risks of Codeine and Tramadol in Children. JAMA. 2017 Oct 17;318(15):1514. doi: 10.1001/jama.2017.13534.

Kelly LE et al. More Codeine Fatalities After Tonsillectomy in North American Children. Pediatrics. 2012; 129(5).

Kirchheiner J, Schmidt H, Tzvetkov M, et al. Pharmacokinetics of codeine and its metabolite morphine in ultra-rapid metabolizers due to CYP2D6 duplication. Pharmacogenomics J. 2007;7(4):257–265

Orliaguet G et al. A Case of Respiratory Depression in a Child With Ultrarapid CYP2D6 Metabolism After Tramadol. Pediatrics. 2015; 135(3).

Poonai N. Analgesia for children in acute pain in the post-codeine era. Curr Pediatr Rev. 2017 Aug 28. doi: 10.2174/157339631366617082911563.1.

 

This post and podcast are dedicated to Bryan Hayes, PharmD for his practical approach to pharmacologic conundrums and to David Juurlink, MD, PhD for his steadfast dedication to patient safety and clinician education.  Check out Bryan's helpful blog and clinical resource, PharmERToxGuy.  Check out David anywhere one utters the word Tra-ma-dol.

Nov 1, 2017

Not all head trauma is minor.

Not all minor head trauma is clinically significant.

 

How can we sort out the overtly ok from the sneakily serious?

 

 

Mnemonics for bedside risk stratification of minor pediatric blunt head trauma, based on PECARN studies:

[Details in Audio]

 

Blunt Head Trauma in Children < 2 years of Age

 

 

Blunt Head Trauma in Children ≥ 2 years of Age

 

 

Image Gently Campaign

 

Medical Imaging Record (maintain like an immunization card)

 

Brochure for Parents: Just in Time Education

 

Selected References

Dayan PS et al. Association of Traumatic Brain Injuries with Vomiting in Children with Blunt Head Trauma. Ann Emerg Med. 2014; 63(6):657-665.

Dayan PS et al. Headache in Traumatic Brain Injuries from Blunt Head Trauma. Pediatrics. 2015; 135(3):504-512.

Horeczko T, Kuppermann N. To scan or not to scan: pediatric minor head trauma in your office, clinic or emergency department. Contemporary Pediatrics. 2012;29(8):40-47.

Kupperman et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-70.

Lee LK et al. Isolated Loss of Consciousness in Children with Minor Blunt Head Trauma. JAMA Pediatr. 2014; 168(9):837-843.

Magana JN, Kuppermann N. The PECARN TBI Rules Do Not Apply To Abusive Head Trauma. Acad Emerg Med. 2017; 24(3)382-384.

Rogers AJ et al. Children with Arachnoid Cysts who Sustain Blunt Head Trauma: Injury Mechanisms and Outcomes. Acad Emerg Med. 2016; 23:358-361.

 

This post and podcast are dedicated to Kevin Klauer, DO, EJD, FACEP for his dedication to education, and for his unique balance of safety and keeping it real.  Thank you.

Oct 1, 2017

Comfortable with G-tubes, tracheostomies, and VP shunts?

Good. 

Get ready for the next level: Vagus Nerve Stimulators, Intrathecal Pumps, and Ventricular Assist Devices.

 

Details in Audio:

Vagus Nerve Stimulators

For intractable epilepsy; sends retrograde signal up corona radiata

Also may be used in: depression, bulimia, Alzheimer, narcolepsy, addiction, and others

VNS magnets

Are VNS safe in MRI?

Are VNS safe in everyday life?

Intrathecal Pumps

Used to infuse basal rate of drug, usually baclofen for spasticity, but pump may contain morphine, bupivicaine, clonidine.  Also used for severe MS, stroke, TBI, chronic pain.  Verify the medication and identify the toxidrome if symptomatic.

Ventricular Assist Devices

May be left ventricular assist, right ventricular assist, or biventricular assist device.

 

References

Vagus Nerve Stimulators (VNS)

Elliott RE, Rodgers SD, Bassani L et al. Vagus nerve stimulation for children with treatment-resistant epilepsy: a consecutive series of 141 cases. J Neurosurg Pediatrics. 2011; 7:491-500.

Groves DA, Brown VJ. Vagal nerve stimulation: a review of its applications and potential mechanisms that mediate its clinical effects. Neuroscience and Biobehavioral Reviews. 2005; 29: 493–500.

Panebianco M, Rigby A,Weston J,Marson AG. Vagus nerve stimulation for partial seizures. Cochrane Database of Systematic Reviews. 2015; 4, Art. No.: CD002896.

Ruffoli R,  Giorgi FS, Pizzanelli C et al. The chemical neuroanatomy of vagus nerve stimulation. Journal of Chemical Neuroanatomy; 2011; 42: 288–296.

Intrathecal Pumps

Borowski A, Littleton AG, Borkhuu B et al. Complications of Intrathecal Baclofen Pump Therapy in Pediatric Patients. J Pediatr Orthop. 2010; 30:76–81.

Ghosh D, Mainali G, Khera J, Luciano M.  Complications of Intrathecal Baclofen Pumps in Children: Experience from a Tertiary Care Center. Pediatr Neurosurg. 2013; 49:138–144.

Yang TF, Wang JC, Chiu JW et al. Ultrasound-guided refilling of an intrathecal baclofen pump—a case report. Childs Nerv Syst. 2013; 29:347–349.

Yeh RN, Nypaver MM, Deegan TJ, Ayyangar R. Baclofen Toxicity in an 8-year-old with an Intrathecal Baclofen Pump. J Emerg Med. 2004; 26(4): 163–167.

Ventricular Assist Devices

Blume ED, Naftel DC, Bastardi HJ et al. for the Pediatric Heart Transplant Study Investigators. Outcomes of Children Bridged to Heart Transplantation With Ventricular Assist Devices: A Multi-Institutional Study. Circulation. 2006; 113: 2313-2319.

Colón JE, Laborde ME, Nossaman BD. Case Report: Left Ventricular Assist Device in a 12 Year Old Child as a Bridge to Heart Transplantation. Section of Congenital Cardiac Anesthesia, Ochsner Medical Center, New Orleans, Louisiana. 2012.

Fan Y, Weng YG, Huebler M et al. Predictors of In-Hospital Mortality in Children After Long-Term Ventricular Assist Device Insertion. J Amer Coll Cardiol. 2011; 58(11):1183–90

Fraser CD,  Jaquiss RDB, Rosenthal DN et al. Prospective Trial of a Pediatric Ventricular Assist Device. N Engl J Med. 2012;367:532-41.

Gazit AZ, Gandhi SK, Canter CC. Mechanical Circulatory Support of the Critically Ill Child Awaiting Heart Transplantation. Current Cardiology Reviews. 2010; 6: 46-53.

VanderPluym CJ, Fynn-Thompson F, Blume ED.  Ventricular Assist Devices in Children Progress With an Orphan Device Application. Circulation. 2014;129:1530-1537.

This post and podcast are dedicated to Joe Bellezzo, MD, FACEP and Zack Shinar, MD, FACEP for bringing us all up to speed.  Listen to their fantastic ED ECMO podcast here.

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