Slipped capito-femoral epiphysis (SCFE) is a favorite board exam topic, and typically involves a young early or pre-adolescent obese girl with hip pain and the classic "ice cream falling off the cone" appearance on hip radiographs. However, keep these three pearls in mind when thinking about SCFE:
As RSV season approaches, remember these key points in managing bronchiolitis:
A common debate on the topic of pediatric burns is whether or not blisters should be debrided. ALL PEDIATRIC BURN BLISTERS SHOULD BE DEBRIDED. There are two reasons for this:
1. Without debridement of burn blisters, the depth of a burn cannot be assessed, and such an assessment will certainly affect treatment and disposition.
2. There is conflicting (poor) evidence that blister fluid provides both protective and damaging properties, however, there is excellent evidence that ruptured blisters, or large blisters which are likely to rupture, carry a higher risk of infection if not debrided. Therefore, all blisters should be debrided.
The best method for debriding blisters uses sterile gauze soaked in saline, and it is important to note that pain is almost universally decreased after debridement.
The "1, 2, 3 Ouch!" technique is exactly what it sounds like (count to three with the child, and then wipe quickly, like tearing off a bandage), and works well in older children with smaller burn areas. Sedation may be necessary for extensive debridements, and these children may need to be taken to the OR for debridement under anesthesia. Some burn centers utilize non-operating room anesthesia (NORA) areas for such debridements that may be prolonged or painful, but do not require the full resources of an operating room.
Pediatric Ethanol Ingestion
A young child is brought to you after accidentally drinking a shot of alcohol at a wedding party. Here is what you need to consider:
Current American Burn Association guidelines state that any child with a greater than 10% total body surface area (TBSA) burn should be admitted to a center capable of caring for pediatric burns, rather than being discharged after wound management. However, physician use of TBSA% estimation techniques is variable. An excellent free tool for estimating TBSA is available online, allows for automatic weight based calculation, and allows printing of your diagram. The diagram is available at http://www.sagediagram.com/. More to come...
Hyperpronation: This reduction technique for a nursemaid's elbow (radial head subluxation) has been found to have better first attempt success than classic supination/flexion technique. (Pediatrics July '98). Support the elbow with a finger on the radial head, and forcefully hyperpronate.
Once you've made the presumptive diagnosis of cerebral edema in Pediatric DKA (refer to part 1), here's what's next:
Mortality from cerebral edema in DKA is 20-25%, and 15-35% of survivors have permanent disability.
The best strategy is to do your best to avoid cerebral edema in the first place, but if you do recognize it, this is a clinical diagnosis, and you should not delay treatment for radiographic studies.
EMTALA stipulates that any patient presenting to the Emergency Department is required to receive a medical screening exam regardless of age, ability to pay, or whether or not a parent accompanies the child.
EMTALA supersedes any state/local provisions or laws.
In performing a medical screening exam if an emergency medical condition exists then diagnostic testing, surgery or even transfer of hospitals may be appropriate without ever obtaining parental consent
MInors have the right to give or refuse informed assent of a procedure
If their is conflict between physician, parent or patient in the rendering of emergent care the physician must weigh the severity of the condition, risks and benefits of the treatment, as well as the patients maturity and cognition. The physician may have to seek ethical committee review, or assistance from either social services or the court system.
If an emergent condition does not exist, EMTALA does not apply after the MSE.
...more to come.
Congenital hypothyroidism (CH) is almost uniformly identified before symptoms develop because of newborn screening. Though this problem will rarely present to the Emergency Department, it is not uncommon for parents with poor access to care to present to EDs after being notified of an abnormal screen. Here is what you need to know:
So:
Precedex (Dexmedetomidine) - Great for pediatric imaging procedures
Alpha-2 agonist with sedative properties
No analgesic effect alone, but shown to decrease the amount of opioids required for a painful procedure
Benefits pts go to sleep and awake in a more natural state. Caregivers tend to prefer this as opposed to other sedatives. Short recovery time- about 30 minutes
Adverse effects include bradycardia and hypotension. Not recommended in any child with cardiac abnormalities. Paradoxical hypertension with loading dose has also been observed
Effective for MRI or CT scans at loading doses of 2mcg/kg over ten minutes, then maintenance of 1mcg/kg/hr
Residents can gain experience with Precedex with Peds sedation on M,W,F mornings with sedation team, contact me to arrange a time for you to participate.
The umbilical site normally heals by 1 month of age.
Any fluid draining after this period suggests an abnormal connection between the surface of the abdomen and the underlying structures, and requires further investigation. Clear yellow fluid could represent a persistent connection of the bladder with the umbilicus called a patent urachus. The fluid that leaks is actually urine. The treatment is surgical closure of the connection.
Pus oozing from the umbilical stump would imply infection, especially if there is concomitant redness of the skin around the umbilicus. An omphalitis can be life-threatening, and requires admission for invtravenous antibiotics.
Umbilical hernias are common in infants, and are usually noted with diastasis of the rectus muscles. Most umbilical hernias resovle by school age, and do not require surgical intervention.
An umbilical granuloma is a small piece of bright red, moist flesh that remains in the umbilicus after cord separation. It is scar tissue, usually on a stalk, that did not become normally covered with skin cells. It contains no nerves and has no feeling. Most can be simply cauterised with silver nitrate.
Pediatric Constipation is a common presentation to PED and large percentage of GI clinic patient volume
Defined as less than 2 stools per week for two weeks with hard, large pellet like stools
Broad Differential includes functional constipation (most common), stricture, obstruction, celiac disease, Hirschsprung, hypothyroid, Cow's milk protein allergy, CF and spina bifida. Always inspect the spine and perform rectal
Success of treatment is based on the aggressive nature of treatment and timing of treatment. Ttreatment is longer and more difficult if patient has to wait on referral to GI specialist.
Hyperleukocytosis is often seen in acute presentations childhood leukemias, and is defined as a WBC count of greater than 30-50K. Complications usually arise at counts greater than 300, however, keep in mind that automated cell counters may underestimate very high white counts.
Complications include:
Treatment: