Pediatric Emergency Playbook

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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. Pe

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 b

Traditional Approach:   Secretory -- poisoned mucosal villi -- "the sieve" Cytotoxic -- destroyed mucosal villi -- "the shred" Osmotic -- malabsorption -- "the pull" Inflammatory -- edema, motility -- "the push" Lots of overlap, difficult to apply to clinical signs and symptoms.   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, especiall

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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.   National Pediatric Readiness Project (NPRP)            Los Angeles County Pediatric Readiness Project    

PEMplaybook.org

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    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"             Yin et al. Bedside Escharotomies for Burns     Classic Paragraph 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

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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 Clef

https://www.youtube.com/watch?v=cQVKIpLc8bk   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.

    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.  

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,

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, Jum

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