Cyanotic (right to left shunt) Congenital Heart Disease (CHD) lesions can be easily remembered with the 1,2,3,4,5 method.

1- Truncus Arteriosis (ONE trunk)

2- Transposition of the Great Vessels (TWO vessels flipped)

3- TRIcuspid Atresia

4-TETRAlogy of Fallot

5- Total Anomolous Pulmonary Venous Return (TAPVR=5 words/letters)

A few other important DUCTAL-DEPENDENT lesions: Coarctation of the Aorta, Hypoplastic Left Heart Syndrome, and Pulmonary Atresia.

Patients present to the emergency department within the first week of life in severe distress, including hypoxia, tachypnea, and hypotension.  The above cyanotic CHD all reflect DUCTAL-DEPENDENT lesions, meaning they need a widely open PDA (which closes in the first week of life) to maintain sufficient oxygenation for viability.

These patients will not survive without timely intervention with prostaglandin (PGE1), so be sure to initiate this life-saving medication as soon as possible!  Side effects include apnea…be prepared to intubate your neonate!

Now that respiratory season is upon us, we are faced with an increasing number of bronchiolitis children. The updated clinical practice guidelines for managing these kids were recently published and emphasize supportive care only.

Some of the key points:

-When clinicians diagnose bronchiolitis on the basis of history and physical examination, radiographic or laboratory studies should not be obtained routinely.

-Medications such as albuterol, nebulized epinephrine or steroids should not be administered routinely in children with a diagnosis of bronchiolitis.

-Nebulized hypertonic saline should not be administered to infants with a diagnosis of bronchiolitis in the emergency department

-Clinicians may choose not to administer supplemental oxygen if the oxyhemoglobin saturation exceeds 90% in infants and children with a diagnosis of bronchiolitis

-Clinicians may choose not to use continuous pulse oximetry for infants and children with a diagnosis of bronchiolitis.

Check out the full guidelines for the quality of evidence and rational behind these recommendations.

The bottom line is that not much really works, and we just need to support their respiratory effort and ensure hydration.

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• Irregular bowel movements and constipation are a common complaint pediatric complaint.
• The majority of cases are functional, but providers should take extra care to rule out organic causes like Hirschsprung's disease particularly during the neonatal period. 
• 1 in 5000 incidence, with abnormal innervation of the distal colon resulting in tonic contraction, and obstruction of feces.
• In most cases, the agangionic segment is limited to the rectosigmoid area.
• Symptoms usually begin in the first month of life and consist of obstuctive complications such as abdominal distension, bilious vomiting, and poor feeding.
• Rectal examination should be done in all patients with constipation, and often reveals a narrowed high-pressure region adjacent to the anal sphincter.
• Barium enema, anal manometry, and rectal biopsy all aid in the diagnosis.

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Dehydration is a common pediatric ED presentation. Oral rehydration (although first choice) is often not possible secondary to patient cooperation and/ or persistent vomiting. Intravenous (IV) hydration is often difficult, requiring multiple attempts especially in the young dehydrated infant.

Hyaluronan is a mucopolysaccharude present in connective tissue that prevents the spread of substances through the subcutneous space. Hyaluronidase is a human DNA-derived enzyme that breaks down hyaluronan and temporarily increases its permeability, thereby allowing fluid to be absorbed with the capillary and lymphatic systems.

In one study, patients age 1 month to 10 years were randomized to recieve 20 mL/kg bolus NS via subcutaneous (SC) or IV route over one hour, then as needed. The mean volume infused in the ED was 334.3 mL (SC) vs 299.6 mL (IV). Succesful line placement occured in all 73 SC patients and only 59/75 IV patients. There was a higher proportion of satisfaction for clinicians and parents for ease of use and satisfaction, respectively.

Bottom line: Consider subcutaneous hyaluronidase faciliated rehydration in mild to moderately dehydrated children, especially with difficult IV access.

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Emergency Physician Bedside Ultrasound for Appendicitis

Why?

To reduce length of stay, improve patient care, and reduce radiation exposure in young patients.

How?

Start with pain medication so you get a better study. (Consider intranasal fentanyl for quicker pain relief and diagnostics in pediatrics.) Study results are also improved with a slim body habitus.

Place the patient supine

Use a high-frequency linear array transducer

Start at the point of maximal tenderness in the RLQ

Transverse and longitudinal planes "graded compression" to displace overlying bowel gas which usually has peristalsis (See Sivitz, et al article for images of "graded compression")

Appendix is usually anterior to the psoas muscle and iliac vein and artery as landmarks

Measure from outer wall to outer wall at the most inflamed portion of the appendix (usually distal end)

Example:

Positive study:

A non-compressible, blind-ending tubular structure in the longitudinal axis >6 mm without peristalsis (see second image above with 8.3 mm diameter measurement)

A target sign in the transverse view (see first image above)

Additional suggestive findings: appendiceal wall hyperemia with color Doppler, appendicoliths hyperechoic (white) foci with an anechoic (black) shadow, periappendiceal inflammation or free fluid

Negative study:

Non-visualization of the appendix with adequate graded compression exam in the absence of free fluid or inflammation.

Limitations for visualization and possible false negative result:

Retrocecal appendix and perforated appendix are difficult to visualize with US.

Pitfalls:

US has good specificity (93% in Sivitz et al article), but limited sensitivity (85% in Sivitz et al article), so trust your clinical judgement. You may need a MRI (pregnant/pediatrics) or CT as they have improved, but not perfect sensitivity.

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Attachments

• 1411081818_Appendicitis_Blind_End_Pouch_US.jpg (1,372 Kb)
• 1411081818_Target_Sign_US_Appendix.jpg (1,461 Kb)

The world of pediatrics is still working on catching up to adult literature in terms of lactate utilization and its implications.  The study referenced looked at over 1000 children admitted to the pediatric intensive care unit. Lactate levels were collected  2 hours after admission and a mortality risk assessment was calculated within 24 hours of admission (PRISM III).  Results showed that the lactate level on admission was significantly associated with mortality after adjustment for age, gender and PRISM III score.

Bottom line:  In your critically ill pediatric patient, lactate may be a useful predictor of mortality.  

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• For uncomplicted community acquired pneumonia which is treated as an outpatient, high dose amoxicillin (80-90mg/kg/day) is the first-line antibiotic of choice.
• Macrolides and third-generation cephalosporins are acceptable alternatives, but are not as effective due to pneumococcal resistance and lower systemic absorption, respectivley.
• Hospitalization should be strongly considered for children younger than 2 months or premature due to an increased risk for apnea.
• Patients hospitalized only for pneumonia, should be treated with ampicillin while those who are septic should be treated with a combination of vancomycin along with a second- or third- generation cephalosporin.

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Question

Q: What is wrong with this baby? And what Dx should you entertain?

Previously healthy 7d old presents after difficulty feeding, one episode of vomiting and now with intermittent apneic episodes.

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• 1410041359_Clavicle_Fracture.jpg (1,743 Kb)

There are numerous different causes of pediatric hemorrhagic diarrhea. Consider a pediatric patient with bloody diarrhea as being at risk for developing hemolytic uremic syndrome. Most cases of hemolytic uremic syndrome are caused by O157:H7 strains of E Coli that release Shiga-like toxin from the gut. Systemic release of the toxin causes microvascular thromboses in the renal microvasculature. The characteristic microangiopathic hemolysis results with anemia, thrombocytopenia and peripheral schistocytes seen on laboratory studies, in addition to acute renal failure.

Antibiotics have been controversial in the treatment of pediatric hemorrhagic diarrhea due to concern that they worsen toxin release from children infected with E Coli O157:H7 and thus increase the risk of developing hemolytic uremic syndrome. Numerous previous studies have provided conflicting data regarding the true risk (1). A recent prospective study showed antibiotic treatment increases the risk (2). Most recommendations warn against using antibiotics to treat pediatric hemorrhagic diarrhea unless the patient is septic.

Bottom line: Avoid treating pediatric hemorrhagic diarrhea with antibiotics

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Question

16 yo M with pleuritic right upper chest pain that started today.  He is suffering from an asthma exacerbation currently in the setting of URI with cough.  He is afebrile, tachycardic to 140-150s, respiratory rate 20, and sats 98% on room air.  ECG was performed which incidentally diagnosed this patient WPW and he went for ablation as an outpatient.  His chest x-ray showed:

Besides a bad day, what do we call this chest x-ray finding?

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Attachments

• 1409221530_IMG_5821.jpg (1,850 Kb)

The NEXUS criteria is widely applied to adults who present with neck pain due to trauma.  While this study did include about 2000 pediatric patients, there were not enough young children to draw definitive conclusions.  For more information on the evaluation of the cervical spine, see Dr. Rice's pearl from 9/7/12.  A 2003 study piloted an algorithm for cervical spine clearance in children < 8 years.

Patients were spine immobilized if: unconscious, abnormal neurological exam, history of transient neurological symptoms, significant mechanism of injury, neck pain, focal neck tenderness or inability to assess based on distracting injury (extremity or facial fractures, open wound, thoracic injuries, or abdominal injuries), physical exam findings of neck trauma, unreliable exam due to substance abuse, significant trauma to the head or face, or inconsolable children.

When the 2 pathways (see attached) were implemented, there was a decrease in time to cervical spine clearance.  There were no missed injuries in the study period prior to implementation of the pathway or once it was implemented.  There was no significant difference in the amount of xrays, CT scans or MRIs.

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Attachments

• 1409192317_Cspine_clearence_pathway.docx (52 Kb)

• The human enterovirus D68 is a rare virus closely related to the rhinovirus which causes the common cold.  However, there have been recent outbreaks throughout the midwest and the areas are rapidly expanding.
• Mild symptom onset of rhinorrhea and cough rapidly progress to hypoxia and respiratory distress.
• Key features are the rapid progression, presence of wheezing even without a history of reactive airway disease, and typically an absence of consolidation on chest XR.
• Children under 5 years and those with asthma are at the greatest risk for respiratory failure.
• There are a limited number of labs in the US which test specifically for EV-D68. At UMMC, the Luminex respiratory virus panel can be ordered using the kit form which includes a flocked swab and viral transport media.  Unfortunately, the panel does not differentiate between the closely related enterovirus and rhinovirus. 
• There is no definitive cure, rather only supportive care and low-threshold for admission/observation for high risk patients.

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6-7% of kids presenting with upper respiratory symptoms will meet the definition for ABS.

The American Academy of Pediatrics (AAP) reviewed the literature and developed clinical practice guideline regarding the diagnosis and management of ABS in children and adolescents.

The AAP defines ABS as: persistent nasal discharge or daytime cough > 10 days OR a worsening course after initial improvement OR severe symptom onset with fever > 39C and purulent nasal discharge for 3 consecutive days.

No imaging is necessary with a normal neurological exam.

Treatment includes amoxicillin with or without clauvulinic acid (based on local resistance patterns) or observation for 3 days.

Optimal duration of antibiotics has not been well studied in children but durations of 10-28 days have been reported.

If symptoms are worsening or there is no improvement, change the antibiotic.

There is not enough evidence to make a recommendation on decongestants, antihistamines or nasal irrigation.

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• Only treat strep pharyngitis after confirmed via rapid antigen test or culture
• Remember the rapid antigen test has high specificity, but low sensitivity.  All negative rapid antigen tests should be followed up with a confirmatory culture
• Traditionally, strep pharyngitis was treated with penicillin V, 250mg PO tid for children and 500 mg tid for adolescents. This was then changed to bid dosing.
• Now, consider treating with amoxicillin, 50mg/kg once daily (max 1000mg). Once daily dosing and better taste improve compliance 

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Up to 26% of patients with tympanostomy tubes (PE tubes) can suffer from clinically manifested otorrhea.  This is thought to be the result of acute otitis media that is draining through the tube. Previous small studies suggested that antibiotic ear drops are as effective or more effective and with less side effects for its treatment.  This study compared treatment with antibiotic/glucocorticoid ear drops (hydrocortisone-bacitracin-colistin) to oral Augmentin (30 mg/kg/TID) to observation for 2 weeks.

Study population: Children 1-10 years with otorrhea for up to 7 days in the Netherlands
Exclusion criteria included: T > 38.5 C, antibiotics in previous 2 weeks, PE tubes placed within 2 weeks, previous otorrhea in past 4 weeks, 3 or more episodes of otorrhea in past 6 months
Patient recruitment: ENT and PMD approached pt with PE tubes and they were told to call if otorrhea developed and a home visit would be arranged
Study type: open-label, pragmatic, randomized control trial
Primary outcome: Treatment failure defined as the presence of otorrhea observed otoscopically
Secondary outcome: based on parental diaries of symptoms, resolution and recurrence over 6 months

Results: After 2 weeks, only 5% of the ear drop group compared to 44% of the oral antibiotic group and 55% of the observation group still had otorrhea.  There was not a significant difference between those treated with oral antibiotics and those that were observed.  Otorrhea
lasted 4 days in the ear drop group compared to 5 days with oral antibiotics and 12 days with observation (all statistically significant).

Key differences:  The antibiotic dosing and choice of ear drops are based on availability and local organism susceptibility.

Bottom line:  For otorrhea in the presence of PE tubes, ear drops (with a non-aminoglycoside antibiotic and a steroid) may be more beneficial than oral antibiotics or observation.

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• Over the last decade, multiple studies have shown that pain and sedation in children can be easily and quickly treated via intransal administration of traditional drugs.
• Inexpensive atomizers are used to quickly administer medications which are absorbed through the mucosal surface and rapidly delivered to the bloodstream and CNS with equivalent effects to intravenous administration.
• Considerations include using concentrated forms as volumes greater than 1mL per nostril may over-saturate the mucosa and drip out rather than be fully absorbed.
• The few side effects included cough, vocal cord irritation, and laryngospasm; but pre-treating with a single puff of lidocaine spray minimizes them and has been found to enhance sedative effects.
• Fentanyl, 2mcg/kg for pain
• Midazolam, 0.2 - 0.5mg/kg for sedation and antiepileptic.
• Ketamine and Dexmedetomidine have also been used with success, but standardized doses are still being studied. 

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Mental health-related visits account for 1.6–6% of ED encounters.  Patients with acute psychosis are often brought to the ED for clearance prior to psychiatric evaluation.  Is this necessary?

Background: Several adult studies have shown that only 0–4% of patients with isolated psychiatric complaints have organic diagnoses requiring urgent treatment.  Routine ED laboratory testing in adults is low yield still, with one study identifying abnormalities in only 2 of 352 patients—both mild hypokalemia.  A pediatric study found that 207 of 209 patients were medically cleared.

This study was a retrospective review of pediatric psychiatric patients presenting to a an urban California hospital.  They examined 798 patients who had an involuntary psychiatric hold placed by a psychiatric mobile response team.
 

• 72 (9.1%) were determined to require medical screening (based on patient complaints).
• Only 35 (4.4%) holds were found to require further medical care prior to psychiatric hospitalization.
• Total charges for laboratory assessments, secondary ambulance transfers and wages for sitters were $1,241,295 or US$17,240 per patient requiring a medical screen.
• Patients were in the ED for an average of 7 h with a cumulative time of 5538 hours.

The authors concluded that few pediatric patients brought to the ED on an involuntary hold required a medical screen and perhaps use of basic criteria in the prehospital setting to determine who required a medical screen (altered mental status, ingestion, hanging, traumatic injury, unrelated medical complaint, sexual assault) could have led to significant savings.

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Scabies is considered by the WHO to be one of the main neglected diseases with approximately 300 million cases worldwide each year. One third of cases of scabies seen by dermatologists are in kids less than 16 years old. The belief had been that presentation varies by age.  One French study reported a first time miss rate of more than 41% and an overall diagnostic delay of 62 days.
 

A prospective, multi center observational study of patients with confirmed scabies sought to determine common phenotypes in children. All patients were seen by dermatologists in France and administered standard questionnaires.  They were divided into 3 age groups, <2 years, 2-15 years and > 15 years.  323 patients were included.

The study found that: 
-infants were more likely to have facial involvement and nodules, especially on the back and axilla
-relapse was more common in < 15 year olds - this was hypothesized to be due to poor compliance with treatment to the head
-family members with itch, or planter or scalp involvement were independently associated with diagnosis of scabies in kids < 2 years
-burrows were seen in 78%, nodules in 67% and vesicles of 43% of patients (see photo)
-itching was absent in up to 10% of patients

Bottom line:  Have a high suspicion for scabies in any rash.

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Attachments

• 1404180657_scabies_figures.docx (1,793 Kb)