Pediatric Emergency Playbook

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Myocardial infarction (MI) in children is uncommon, but underdiagnosed.  This is due to two main factors: the etiologies are varied; and the presenting symptoms are “atypical”. We need a mental metal detector!  Case examples Congenital Two main presentations of MI due to congenital lesions: novel and known.  The novel presentation is at risk for underdiagnosis, due to its uncommonness and vague, atypical symptoms.  There are usually some red flags with a careful H&P.  The known presentation is a child with a history of congenital heart disease, addressed by corrective or palliative surgery.  This child is at risk for expected complications, as well as overdiagnosis and iatrogenia.  Risk stratify, collaborate with specialists. The fussy, sweaty feeder: ALCAPA Anomalous Left Coronary Artery from the Pulmonary Artery (ALCAPA) is an example of what can go wrong during fetal development: any abnormality in the number, origin, course, or morphology of the coronary arteries can present as a neonate with sweat

Most newborns will have some jaundice.  Most jaundice is benign. So, how can we sort through the various presentations and keep our newborns safe? Pathologic Jaundice When a baby is born with jaundice, it’s always bad.  This is pathologic jaundice, and it’s almost always caught before the baby goes home.  Think about ABO-incompatbility, G6PD deficiency, Crigler-Najjar, metabolic disturbances, and infections to name a few.  Newborns are typically screened and managed. Physiologic Jaundice Physiologic jaundice, on the other hand, is usually fine, until it’s not. All babies have some inclination to develop jaundice.  Their livers are immature.  They may get a little dehydrated, especially if mother’s milk is late to come in.  In today’s practice, we are challenged to catch those at risk for developing complications from rising bilirubin levels. Hyperbilirubinemia is the result of at least one of three processes: you make too much, you don’t process it enough, or you don’t get rid of it fast enough. Increased pro

Children the world over are fascinated with what can possibly “fit” in their orifices.  Diagnosis is often delayed.  Anxiety abounds before and during evaluation and management.     Most common objects:1,2 Food Coins Toys Insects Balls, marbles Balloons Magnets Crayon Hair accessories, bows Beads Pebbles Erasers Pen/marker caps Button batteries Plastic bags, packaging Non-pharmacologic techniques Set the scene and control the environment.  Limit the number of people in the room, the noise level, and minimize “cross-talk”.  The focus should be on engaging, calming, and distracting the child. Quiet room; calm parent; “burrito wrap”; guided imagery; have a willing parent restrain the child in his or her lap – an assistant can further restrain the head. Procedural Sedation Most foreign bodies in the ear, nose, and throat in children can be managed with non-pharmacologic techniques, topical aids, gentle patient protective restraint, and a quick hand.  Consider sedation in children with special health

When you give only after you're asked, you've waited too long. – John Mason First, learn to bag Place a towel roll under the scapulae to align oral, pharyngeal, and tracheal axes: Karsli C. Can J Anesth. 2015. Use airway adjuncts such as the oropharyngeal airway or a nasal trumpet. Use the two-hand ventilation technique whenever possible:   (See Adventures in RSI for more)     Supraglottic Airways: for difficult bag-valve-mask ventilation or a difficult airway (details in audio) LMA Classic Pros: Best studied; sizes for all ages Cons: Cannot intubate through aperture   LMA Supreme Pros: Better ergonomics with updated design; bite bloc; port for decompression Cons: Cannot pass appropriate-sized ETT through tube   King Laryngeal Tube Pros: Little training needed; high success rate; single inflation port Cons: Flexion of tube can impede ventilation or cause leaks; only sized down to 12 kg (not for infants and most toddlers)   Air-Q Pros: Easy to place; can intubate through aperture

When should you commit to getting urine? When can you wait? When should you forgo testing altogether? When do I get urine? Symptoms – either typical dysuria, urgency, frequency in a verbal child, or non-descript abdominal pain or vomiting in a well appearing child. Fever – but first look for an obvious alternative source, especially viral signs or symptoms. No obvious source? Risk stratify before “just getting a urine”. In a low risk child, with obviously very vigilant parents, who is well appearing, you may choose not to test now, and ensure close follow up. Bag or cath? The short answer is: always cath, never bag. (Pros and cons in audio) What is the definition of a UTI? According to the current clinical practice guideline by the AAP, the standard definition of a urinary tract infection is the presence of BOTH pyuria AND at least 50 000 colonies per mL of a single uropathogen. Making the diagnosis in the ED: The presence of WBCs with a threshold of 5 or greater WBCs per HPF is required. What else

N.B.: This month's show notes are a departure from the usual summary.  Below is a reprint (with permission) of a soon-to-be released chapter, Horeczko T. "Acute Pain in Children". In Management of Pain and Procedural Sedation in Acute Care. Strayer R, Motov S, Nelson L (eds). 2017.  Rather than the customary blog post summary, the full chapter (with links) is provided as a virtual reference. INTRODUCTION Pain is multifactorial: it is comprised of physical, psychological, emotional, cultural, and contextual features.  In children often the predominant feature may not be initially apparent.  Although clinicians may focus on the physical component of pain, much time, energy, and suffering can be saved through a holistic approach.  What is the age and developmental stage of the child?  How is the child reacting to his condition?  What are the circumstances?  What is the family or caregiver dynamic? We rely much on how patients and families interact with us to gauge pain.  Assessing and managing children’s pain ca

"By the pricking of my thumbs, Something wheezing this way comes." -- Witches in Macbeth, with apologies to William Shakespeare   "Bronchiolitis is like a pneumonia you can’t treat. We support, while the patient heals." -- Coach, still apologetic to the Bard     The Who The U.S. definition is for children less than two years of age, while the European committee includes infants less than one year of age. This is important: toddlerhood brings with it other conditions that mimic bronchiolitis – the first-time wheeze in a toddler may be his reactive airway response to a viral illness and not necessarily bronchiolitis. The What The classic clinical presentation of bronchiolitis starts just like any other upper respiratory tract infection: with nasal discharge and cough, for the first 1-2 days. Only about 1/3 of infants will have a low-grade fever, usually less than 39°C. We may see the child in the ED at this point and not appreciate any respiratory distress – this is why precautionary advice is so important in g

Johnny has fallen on an outstretched hand, and comes to you with a swollen, painful elbow.   Position of comfort, analgesia, xrays, and now what?   What am I seeing -- or not seeing -- here?     First a refresher on radiographic anatomy of the elbow --   Images courtesy of Radioglypics (Open Access Radiology Education). Used with permission. Now that we have our adult anatomy reviewed, let's go through the development of the elbow in a child. We are all born with primary ossification centers -- the basic shapes of our long bones.  Secondary ossification centers then develop around the ends of our long bones, and make interpretation of films in the context of suspected injury difficult. Elbow Interpretation Roadmap: CRITOE More pragmatic and utilitarian than a prosaic mnemonic, CRITOE helps us to remember the order of ossification of the pediatric elbow. Although children develop at different rates, the order of ossification is programmed into us.  Images courtesy of Radiopaedia.   Capitellum By age one, the

Blood in the vomit. Blood in the stool. Blood in the diaper. How far do I go in my investigation? What do I really have to worry about?   The differential diagnosis of GI bleeding in children is broad. (Here is the complete differential diagnosis) In the ED, we can simplify by categorizing by age and appearance.     Neonates GI bleeding in the neonate (less than one month of age) is serious until proven otherwise. Well appearing? If this in obvious anal fissure, then no further work-up is necessary.  Counsel on proper feeding and follow-up. Evaluate for potential swallowed maternal blood by examining mother with a chaperone, then perform the Apt test. Consider allergic proctocolitis if the child is well.  Counsel the breastfeeding mother on diet modification.  If formula fed, the child should feed through thus until the primary care physician decides whether to start the sticky process of changing up formulas. If unclear, consider a complete blood count and/or further work-up and admission if unwell. Ill

Seemingly vague, but potentially dangerous... common, but possibly with consequences... ...or maybe just plain frustrating. Let's talk risk stratification, diagnosis, and management. Primary or Secondary? We can make headache as easy or as complicated as we like, but let's break it down to what we need to know now, and what the parents need to know when they go home. Primary headaches: headaches with no sinister secondary cause – like tension or migraine – are of course diagnoses of exclusion (cluster headache is exceedingly rare in children). Secondary headaches: headaches due to some underlying cause -- are what we need to focus on first. The list of etiologies is vast; here is just a sampling: How do I sort this out? Ask yourself three main questions: Is it a tumor? Is it an infection? Is it a bleed? Is it a tumor? Some historical features are high-yield in screening for signs or symptoms consistent with a space occupying lesion. Progression and worsening of symptoms over time Associated vomiting Pain

Have you ever been in any of these situations? ⇒   You have a stable child who just needs fluids, but no laboratory tests ⇒   You’ve tried PO hydration, to no avail, despite anti-emetics ⇒   You’re poking the stable, but dehydrated child repeatedly without success What now? Hypodermoclysis, otherwise known as subcutaneous rehydration. [Insert Player] Clysis comes from the same Greek word that “a flood” – hypodermoclysis refers to flooding the subcutaneous space with fluid, so that it can be absorbed systemically. Sound far-fetched? Well, it turns out, what is old is new again. In 1913, Dr Day first described this technique for a child with severe diarrhea who could not tolerate fluids by mouth. Hypodermoclysis then began to gain popularity with a peak of use in the 1940s, until an innovative breakthrough in 1950. Dr David Massa, a resident anesthesiologist at the Mayo clinic, invented the first catheter-over-needle apparatus. With increasing safety and ready access of IV catheters, IV quickly overshadowed SC

"She won't walk", or "He just looks like he's limping". So many things can be going on -- how do we tackle this chief complaint? You’re dreading a big work-up.  You almost want to tell the kid – please, STOP LIMPING... STOP LIMPING! S – Septic Arthritis  The most urgent part of our differential diagnosis. The hip is the most common joint affected, followed by the knee.  Lab work can be helpful, as well as US of the hip to look for an effusion,  but sometimes, regardless of the results, the joint just has to be tapped to know for sure. T – Toddler’s fracture This is usually a torque injury when the wobbling toddler pivots quickly or trips and falls.  Toddler’s fractures happen in children 1 to 3 years of age, and occur in the distal 1/3 of the tibia.  Sometimes a cast is needed, but currently there is a new trend in foregoing casting in mild cases. O – Osteomyelitis Bacteremia – from any source – can seed into any bone.  It’s not very common, but it happens: approximately 2% of children who present to an ED wi

Do we recognize shock early enough? How do we prioritize our interventions? How can we tell whether we’re making our patient better or worse?   World wide, shock is a leading cause of morbidity and mortality in children, mostly for failure to recognize or to treat adequately. So, what is shock? Simply put, shock is the inadequate delivery of oxygen to your tissues.  That’s it.  Our main focus is on improving our patient’s perfusion. Oxygen delivery to the tissues depends on cardiac output, hemoglobin concentration, the oxygen saturation of the hemoglobin you have, and the environmental partial pressure of oxygen. At the bedside, we can measure some of these things, directly or indirectly.  But did you notice that blood pressure is not part of the equation?  The reason for that is that blood pressure is really an indirect proxy for perfusion – it’s not necessary the ultimate goal. The equation here is a formality: DO2 = (cardiac output) x [(hemoglobin concentration) x SaO2 x 1.39] + (PaO2  x 0.003)     Sho

How do you approach the child who may be altered?   Altered mental status in children can be subtle.  Look for age-specific behaviors that range from irritability to anger to sleepiness to decreased interaction. In the altered child, anchoring bias is your biggest enemy.  Keep your mind open to the possibilities, and be ready to change it, when new information becomes available. For altered adults, use AEIOU TIPS (Alcohol-Epilepsy-Insulin-Overdose-Uremia-Trauma-Infection-Psychosis-Stroke). Try this for altered children: remember that they need their VITAMINS! V – Vascular (e.g. arteriovenous malformation, systemic vasculitis) I – Infection (e.g. meningoencephalitis, overwhelming alternate source of sepsis) T – Toxins (e.g. environmental, medications, contaminated breast milk) A – Accident/abuse (e.g. non-accidental trauma, sequelae of previous trauma) M – Metabolic (e.g. hypoglycemia, DKA, thyroid disorders) I – Intussusception (e.g. the somnolent variant of intussusception, with lethargy) N – Neoplasm (e.g.

It's a busy shift.  Today no one seems to have a chief complaint. Someone sends a troponin on a child.  Good, bad, or ugly, how are you going to interpret the result? And while we’re at it – what labs do I need to be careful with in children – sometimes the normal ranges of common labs can have our heads spinning! Read on to go from bread-and-butter pediatric blood work to answer the question – what’s up with troponin, lactate, d-dimer, and BNP in kids?   A fundamental tenet of emergency medicine:     We balance our obligation to detect a dangerous condition with our suspicion of the disease in given patient. Someone with a cough and fever may simply have a viral illness, or he may have pneumonia.  Our obligation is to evaluate for the pneumonia.  It’s ok if we “miss” the diagnosis of a cold. It could be bad if we don’t recognize the pneumonia.   How do we decide?  Another fundamental concept:     The threshold. Depending on the disease and the particular patient, we have a threshold for testing, and the th

A 5-year-old boy was playing with his older brother in front of their home when he was struck by a car. He sustained a femur fracture, splenic laceration, and blunt head trauma – the so-called Waddell’s triad. On arrival, he was in compensated shock, with tachycardia. He decompensates and needs blood. How do we manage his hemodynamics and when do we perform massive transfusion? Pediatric Massive Transfusion 40 mL/kg of blood products given at any time within the first 24 hours. Adolescents and Adult Massive Transfusion 6-8 units of packed red blood cells (PRBCs) Adults have about 5 L of circulating blood. Not including plasma, one could replace all circulating erythrocytes with about 10 units of PRBCS The best ratio of PRBCs:Plasma:Platelets is unknown, but consensus is 1:1:1. 1 unit of PRBCS is typically 300 mL of volume. The typical initial transfusion of PRBCs in children is 10 mL/kg. Massive transfusion in children is defined as 40 mL/kg of any blood product. Once you start to give a child with major tr

Traumatized children need your full attention. Protocols work well for adults, but trauma in children requires that we exercise our clinical muscles just a bit more.   Two main reasons:  Children have specific injury patterns  Their physiologic response to trauma is unique.   Crash course in pediatric anatomy and physiology in trauma When you think of trauma in children, think of Charlie Brown. Large head, no neck, his chest and abdomen form an underdeveloped, amorphous shape. Alternatively, think of children as apples – they are rounder than they are tall, with a large increased surface area. Apples don’t have a hard shell or thick rind to protect them. If you drop them, you may not see any evidence of damage to the outside, but there can be considerable bruising just under the surface. A child has thin skin, less subcutaneous deposits than an adult, and a non-calcified, pliable thorax that deforms more than it protects or shields. The child’s abdominal muscles are not yet developed. There is less per

In the young child, vomiting is the great imitator: Gastrointestinal, Neurologic, Metabolic, Respiratory, Renal, Infectious, Endocrine, Toxin-related, even Behavioral. To help us organize, below is a review of can't-miss diagnoses by age. The Neonate: Malrotation with Volvulus In children with malrotation, 50% present within the first month of life, with the majority occurring in the first week after birth. 90% of children with malrotation with volvulus will present by one year of age.   This is a pre-verbal child’s disease – which makes it even more of a challenge to recognize quickly. The sequence of events usually is fussiness, irritability, and forceful vomiting.  The vomit quickly turns bilious. Green vomit is a surgical emergency. Babies may also present unwell, with bloating and abdominal tenderness to palpation.  Be aware that later stages of malrotation may present as shock – they present in hypovolemic shock due to third-spacing from necrotic bowel and/or septic shock from translocation or perforat

Victims of electrical injuries present either in extremis or as the seeming well patient with insidious, developing disease. A targeted history usually gets you the information you need.     Four main things to find out: 1. Household or Industrial electricity? Household electricity uses alternating current, or AC.  Voltages across the world range anywhere from 100 to 240 V.  Here in North America, most outlets and appliances use 120 volts, which is the measure of electrical tension, or the potential difference in electrical charge. Cut-off between low voltage and high voltage is 1000 V. Industrial energy may be AC or direct current, DC.  DC current propels the victim -- think of this as a blast injury.  The same voltage in AC is three times as damaging as that voltage at DC, because AC causes muscle tetany, and prolonged contact time. 2. What was the likely pathway that current took? Did the current pass through the thorax?  -- Think dysrhythmias.  Through the head or neck?  -- Think damage to the CNS and ri