Pediatric Emergency Playbook
Pediatric Emergency Playbook
Tim Horeczko, MD, MSCR, FACEP, FAAP
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. Please visit our site at http://PEMplaybook.org/ for show notes and to get involved with the show -- see you there!
Overdose: Too Hot!
PEMplaybook.org
Apr 1
37 min
Constipation and the way out
Constipation as a diagnosis can be dangerous, mainly because it is a powerful anchor in our medical decision-making. Chances are, you’d be right to chalk up the pain to functional constipation — 90% of pediatric constipation is functional, multifactorial, and mostly benign — as long as it is addressed. We’re not here for “chances are“; we’re here for “why isn’t it?“ Ask yourself, could it be: Anatomic malformations: anal stenosis, anterior displaced anus, sacral hematoma Metabolic: hypothyroidism, hypercalcemia, hypokalemia, cystic fibrosis, diabetes mellitus, gluten enteropathy Neuropathic: spinal cord abnormalities, trauma, tethered cord Neuromuscular: Hirschprung disease, intestinal neuronal dysplasia, myopathies, Down syndrome, prune belly syndrome Connective tissue disorders: scleroderma, SLE, Ehlers-Danlos syndrome Drugs: opioids, antacids, antihypertensives, anticholinergics, antidepressants, sympathomimetics Ingestions: heavy metals, vitamin D overload, botulism, cow’s milk protein intolerance   Red Flags Failure to thrive Abdominal distention Lack of lumbosacral curve Midline pigmentation abnormalities of the lower spine Tight, empty rectum in presence of a palpable fecal mass Gush of fluid or air from rectum on withdrawal of finger Absent anal wink       You gotta push the boat out of the mud before you pray for rain.   — Coach     Medications for disimpaction (do this first!) Polyethylene Glycol (PEG) 3350 (Miralax): 1 to 1.5 g/kg PO daily for 3 to 6 consecutive days.  Maximum daily dose: 100 g/day PO.  Follow-up with maintenance dose (below) for at least 2 months (usually 6 months) Lactulose: 1.33 g/kg/dose (2 mL/kg) PO twice daily for 7 days Mineral Oil (school-aged children): 3 mL/kg PO twice daily for 7 days   Medications for Maintenance (do this after disimpaction!) Polyethylene Glycol (PEG) 3350 (Miralax): 0.2 to 0.8 g/kg/day PO.  Maximum daily dose: 17 g/day. Maintenance dosing for Miralax may need to be tailored; up to 1 g/day maintenance.   Lactulose: 1 to 2 g/kg/day (1.5 to 3 mL/kg/day)PO divided once or twice daily.  Maximum daily dose: 60 mL/day in adults. Mineral Oil: 1 to 3 mL/kg/day PO divided in 1 to 2 doses; maximum daily dose: 90 mL/day Docusate (Colace): 5 mg/kg/day PO divided QD, BID, or TID (typical adult dose 100 mg BID) Senna, Bisocodyl — complicated regimens; use your local reference   Enemas Are you sure?  Have you tried oral disimpaction over days? No phosphate enemas for children less than 2. Saline enemas are generally safe for all ages Be careful with the specific dose — please use your local reference   Selected References Freedman SB et al. Pediatric Constipation in the Emergency Department: Evaluation, Treatment, and Outcomes. JPGN 2014;59: 327–333. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Clinical Practice Guideline: Evaluation and Treatment of Constipation in Infants and Children. JPGN 2006; 43:e1-e13. Tabbers MM et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274. Audio Player       00:00   00:0
Mar 1
48 min
Pediatric IV Tips and Tricks
Top 10 [details in audio] Set the stage – exude confidence and be prepared Choose the right cannula size – a smaller working IV is infinitely better than none Feeling is better than looking – trust yourself Mark the site – things get wonky when you take your hands off to disinfect Tourniquets can mess you up – try to use a holder’s hand to occlude the vein The holder rules – get as many hands on deck as you need. Tension is good –  a little counter traction on the skin with your non-dominant hand helps to decrease the friction as the needle goes through the fascial layers. Stay in line – your needle is an extension of your arm Gravity is your friend – the kinder, gentler tourniquet The 3 Fs – flash, flatten, and forward. Get the flash at a 30 degree angle, flatten that angle, (advance another 1mm), and advance the plastic catheter over the needle into success
Feb 1
26 min
Vagal Maneuvers In Children
https://pemplaybook.org/?p=2234
Jan 1
28 min
Conjunctivitis
Dec 1, 2020
44 min
Go or No Go: Pediatric Presedation Assessment
https://pemplaybook.org/?p=2211
Nov 1, 2020
43 min
Caustic Ingestions
https://wp.me/p6B1Mm-zr
Oct 1, 2020
32 min
Pediatric Hand Fractures
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. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009. Extra-Octave Fracture Mims L et al. Extra-Octave Fracture in a 14-Year-Old Basketball Player. Journal of Pediatrics. 2017; 186: P206-206 Same boy, after reduction and ulnar splint Same boy, on follow-up at 17 days Ulnar Collateral Ligament Injury Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009. Bennett Fracture radiopaedia.org Rolando Fracture wikipedia.org Selected References Kiely AL et al. The optimal management of Seymour fractures in children and adolescents: a systematic review protocol. Systematic Reviews. 2020; 9 (150). Liao CY et al. Pediatric Hand and Wrist Fractures. Clin Plastic Surg 46 (2019) 425–436 Lin JS et al. Treatment of Acute Seymour Fractures. J Pediatr Orthop. 2009; 39(1):e23-e27. Mims L et al. Extra-Octave Fracture in a 14-Year-Old Basketball Player. Journal of Pediatrics. 2017; 186: P206-206 Mohseni M et al. Ulnar Collateral Ligament Injury. Stat Pearls. 2020 Nellans et al. Pediatric Hand Injuires. Hand Clin. 2013 November ; 29(4): 569–578 Pattni A et al. Volar Plate Avulsion Injury. Eplasty. 2016; 16: ic22. Stevenson J et al. The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial. The Journal of Hand Surgery: British & European. 2003; 28(5): 388-394 Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009
Sep 1, 2020
43 min
Heat-Related Illness
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 be elevated to 40°C (104°F) Exercise-induced cramping in large muscle groups, especially legs Hydration; consider labs (Cr, total CK); may counsel to stretch muscles passively, gently         Heat tetany May be elevated to 40°C (104°F) Hyperventilation with paresthesia, carpopedal spasm Modify environment; hydration; may place non-rebreather mask on low (or off) for rebreathing CO2         Heat exhaustion Elevated up to 40°C (104°F) Normal mental status, fatigue, that rapidly improves with treatment; tachycardia; GI symptoms; electrolyte abnormalities  Cool environment; hydration; consider labs with severe symptoms, or if not improved          Heat Stroke >40 to 40.5°C   (104 to 105°F) Altered mental status; tachypneic; tachycardic with hypotension; electrolyte abnormalities; GI symptoms; often with renal failure, rhabdomyloysis, renal failure; possibly with cardiogenic shock or ARDS or DIC Rapid cooling with all modalities available (radiation, conduction, convection, evaporation); IV rehydration; labs; monitoring; ICU admission Miliaria Crystallina Miliaria Crystallina — Infant Miliaria Crystallina — Older Child Miliaria Rubra — Infant Miliaria Rubra — Infant Miliaria Rubra — Toddler Miliaria Rubra — Adolescent Miliaria Profunda Selected References Bergeron MF, Devore C, et al. Council on Sports Medicine and Fitness and Council on School Health, Policy statement—Climatic heat stress and exercising children and adolescents. Pediatrics 2011; 128:e741. Casa DJ et al. The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-Practices Recommendations. J Athl Train. 2013 Jul-Aug; 48(4): 546–553. DeFranco MJ et al. Environmental issues for team physicians. Am J Sports Med. 2008 Nov;36(11):2226-37. Ishimine P. Hyperthermia. In: Pediatric Emergency Medicine, Baren JM, Rothrock SG, Brennan JA, Brown L (Eds), Saunders Elsevier, Philadelphia 2008. p.992. Jardine DS. Heat illness and heat stroke. Pediatr Rev 2007; 28:249.
Aug 1, 2020
44 min
Diarrhea
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, especially if under 5 years old: CBC, chemistries, UA, stool culture   Evaluate Hydration Status                 Selected References Khan WA et al. Central Nervous System Manifestations of Childhood Shigellosis: Prevalence, Risk Factors, and Outcome. Pediatrics. 1999 Feb;103(2):E18 Lee JY et al. Diagnostic yield of stool culture and predictive factors for positive culture in patients with diarrheal illness. Medicine (Baltimore). 2017 Jul; 96(30): e7641. Nelson JD et al. Treatment of Salmonella gastroenteritis with ampicillin, amoxicillin, or placebo. Pediatrics 1980; 65:1125.        
Jul 1, 2020
50 min
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