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161-180 of 200 results by Jenny Guyther
A previous pearl has looked at serum HCO3 as a predictor of DKA (see pearl from 8/21/15). The article by Gilhotra looks at using end tidal CO2 (ETCO2) to exclude DKA. 58 pediatric patients were enrolled with 15 being in DKA. No patient with ETCO2 > 30 mmHg had DKA. Six patients with ETCO2 < 30 mmHg did not have DKA. Other studies done in children have shown similar results.
An article recently published by Chebl and colleagues examined patients older than 17 years with hyperglycemia. In this study, 71 patients were included with 32 having DKA. A ETCO2 >35 excluded DKA in this group while a level <22 was 100% specific for DKA.
Bottom line: ETCO2 >35 mmHg is a quick bedside test that can aid in the evaluation of hyperglycemic patients.
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There is not much data published on susceptabilities of urinary pathogens in infants. What resistance patterns are seen in infants < 2 months in gram negative uropathogens?
A retrospective study of previously healthy infants diagnosed with urinary tract infections in Jerusalem over a 6 year period examined this question. The standard treatment at this hospital included ampicillin and gentamycin for less than 1 month olds and ampicillin or cefuroxime for 1-2 month olds.
306 UTIs were diagnosed
74% were resistant to ampicillin
22% were resistant to cefazolin and augmentin
8% were resistant to cefuroxime
7% were resistant to gentamycin
Of the organisms cultured, 76% were E. coli and 14% were Klebsiella.
Bottom line: Know your local resistance patterns.
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ED study of 60 pediatric patients for procedural sedation
- Fentanyl 1 mcg/kg was followed by 0.1 to 0.2 mg/kg of etomidate IV.
- One dose of 0.2 mg/kg IV etomidate was adequate for 39/60 patients
- 16.4% had respiratory depression
- Desaturation occured in 23 patients
- No patient required positive pressure ventilation
- Average recovery in 21 minutes
Bottom line: Etomidate can achieve effective sedation in children for a short procedure. Although respiratory effects were noted, none of them required assisted ventilation.
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Our suspicion of significant abdominal injury increases when there is bruising across the abdomen in adults after a motor vehicle collision, but what about in children? A PECRAN analysis may have provided us with the answer.
Of 3740 pediatric patients after motor vehicle collision, 16% had a seat belt sign. Seat belt sign was defined as a continuous area of erythema, ecchymosis or abrasion across the abdomen due to the seat belt. 1864 children had CT scans of the abdomen. Intra-abdominal injuries (IAI) were more common in those children with seat belt sign than those without (19% versus 12%). Those with seat belt sign had a greater risk of hallow viscous or mesenteric injuries. There was no increased risk of solid organ injury. 33% of patients with seat belt sign did not have complaints of abdominal pain or tenderness on initial exam (with a GCS of 14 or 15); 2% of these patients underwent operative intervention for their injuries.
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Is there a set of criteria similar to the Ottawa Ankle or Knee Rule that can be applied to the wrist in children?
The Amsterdam Pediatric Wrist Rules are as follows:
-Swelling of distal radius
-Visible deformity
-Painful palpation of the distal radius
-Painful palpation at the anatomical snuff box
-Painful supination
A positive answer to any of these would indicate the need for an xray.
The study referenced attempted to validate these criteria. This criteria is inclusive of the distal radius in addition to the wrist. The sensitivity and specificity were 95.9% and 37.3%, respectively in children 3 years through 18 years. This model would have resulted in a 22% absolute reduction in xrays. In a validation study, 7/170 fractures (4.1%, 95% CI: 1.7- 8.3%) would have been missed using the decision model. The fractures that were missed were all in boys ages 10-15 and were all buckle fractures and one non displaced radial fracture.
Bottom line: This rule can serve as a guide for when to obtain an xray in the setting of trauma, but it is not perfect.
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The answer may be no, as long as you have a serum HCO3. In this retrospective study, linear regression was used to to assess serum HCO3 as a predictor of venous pH. Logistic regression was also used to evaluate serum HCO3 as a predictor of DKA. Using a HCO3 cutoff of <18 mmol/L had a sensitivity of 91.8% and specificity of 91.7% for detecting a pH <7.3. A HCO3 < 8 had a sensitivity of 95.2 % and specificity of 96.7 % for detecting a pH <7.1.
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A recent meta-analysis published in Pediatrics reviews the diagnostic accuracy of lung ultrasound for pneumonia. According to the commentary, pneumonia is the leading cause of illness and death in children worldwide; it accounts for 18% of the total number of deaths in children <5 years, more than TB, AIDS, and malaria combined.
They performed a systematic search on several major databases using a combination of controlled keywords for age <18 years, pneumonia, and ultrasound. Of the initially 1475 identified studies, 8 were ultimately chosen for further evaluation.
Characterizing the meta-analysis:
- Three were conducted in the ED, 2 on the wards, 1 in the PICU and 2 in the NICU.
- Of the 765 children encompassed, the mean age was 5 years and they were 52% boys.
- Five of the 8 studies noted using highly skilled sonographers.
- The studies originated from Italy (5), US (1), China (1) and Egypt (1).
- All studies used CXR +/- clinical criteria as the diagnostic standard; LUS assessment was blinded to associated CXR results in 7 of 8 studies.
Results:
- LUS in the diagnosis of pediatric pneumonia had an overall pooled sensitivity of 96% (95% confidence interval [CI]: 94-97%) and specificity of 93% (95% CI: 90-96%).
- Positive and negative likelihood ratios were 15.3 (95% CI: 6.6-35.3) and 0.06 (95% CI: .03-0.11), respectively. For reference, remember that an LR >1 indicates an increased probability that the target disorder is present and >10 is a large or often conclusive increase in the likelihood of disease. Likewise, an LR <1 indicates a decreased probability that the target disorder is present and <0.1 is large or often conclusive decrease in the likelihood of disease.
- The area under the receiver operating characteristic (ROC) curve was 0.98. The ROC curve represents a measure of the accuracy of a test, >0.9 is considered to be excellent.
- In order to determine whether there are genuine differences underlying the results of the studies (heterogeneity) the I-squared statistic was implemented, with values consistent >0.45, demonstrating significant heterogeneity.
Bottom line: LUS appears to be an accurate test for the diagnosis of pneumonia in children. The limitation of this meta-analysis is mainly in the small number of studies and the significant heterogeneity between them, likely due at least in part to the fact that they used CXR +/- clinical data as the diagnostic standard. Nevertheless, the results provide evidence for the use of LUS as a cost-effective tool that potentially eliminates ionizing-radiation from the work-up of pediatric pneumonia and has application potential in resource-limited settings.
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Sodium valproate (VPA) had been studied and found to be effective in the adult population for migraines, but not in the pediatric population. This article was a small (12 patient) retrospective study of pediatric migraine patients looking at pain scores before and after VPA administration. Prior to VPA, patients received NSAIDs, dopamine antagonists, IV fluids and narcotics. Mean pain reduction prior to VPA was 17%. After VPA, pain scores were reduced by an additional 36%.
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Lice are spread through direct contact as they crawl. Indirect contact (through brushes or hats) is less likely. One study showed that live lice were found in only 4% of infested volunteers pillowcases.
During an initial infestation, lice can reside on the head for up to 4 to 6 weeks before becoming symptomatic. Therefore, when lice are detected at school, there is no need to send the child home (or to the ED). Children also do not need to be kept out of school while receiving treatment.
Bonus: First line treatment is 1% Permethrin applied on day 0 and 9. The patient should wash their hair first with a non conditioned shampoo, apply Permethrin for 10 minutes and then rinse.
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Approximately ¼ of lumbar punctures (LP) are traumatic or unsuccessful in infants. What is the implication of this?
A retrospective cross sectional study over a 10 year period at Boston Children’s Hospital looked at infants aged 28 to 60 days who had blood cultures sent from the Emergency Department and who had LPs performed. The ED clinicians at this facility routinely follow the “Boston Criteria” to identify infants at low risk for spontaneous bacterial infection (SBI). Traumatic LPs were defined as CSF red cell count greater than or equal to 10x10^9 cells/L while an unsuccessful LP was defined as one where no CSF was available for cell counts. A small portion of the unsuccessful LPs did not have CSF cultures sent.
173 infants had traumatic or unsuccessful LPs. The SBI rate did not differ between the normal LP and the traumatic and unsuccessful LP infants. Median hospital charges were higher in the traumatic or unsuccessful LPs compared to the normal LP group ($ 5117 US dollars versus $ 2083 US dollars).
Bottom Line: Traumatic or unsuccessful LPs lead to higher hospital charges.
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This study is a case control study of the association of congenital heart disease (CHD) and stroke using a base population of 2.5 million Kaiser patients in California. 412 cases of stroke were identified and compared to 1236 controls. Of these stroke patients, 11/216 ischemic strokes and 4/196 hemorrhagic strokes were attributed to CHD (both cyanotic and acyanotic lesions). CHD was found in 7/1236 controls.
Children with CHD and history of cardiac surgery had the strongest risk of stroke (31 fold over the control group). Many of these children had strokes years after their surgery. Children with CHD who did not have cardiac surgery had a trend towards elevated stroke risk, but the confidence intervals included the null. More children without CHD history presented with headache.
Bottom line: Stroke risk (both hemorrhagic and ischemic) extend past the immediate postoperative period in patients with CHD.
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Of pediatric patients who have anteroposterior (AP) pelvic xrays (XR), there is a 4.6% rate of pelvic fracture or dislocation, compared to 10% in adults.
This study is a sub analysis of a prospective observational cohort of children with blunt torso trauma conducted by PECARN. 7808 patients had pelvic imaging, with 65% of them having an AP XR. The XR sensitivity ranged from 64-82% (based on age groups) for detecting fractures. All but one patient with a pelvic fracture not detected on XR had a CT scan. The CT scan detected all but 2 fractures both of which were picked up later as healing fractures on repeat pelvic XR. Some of the patients who had a missed fracture on XR were hemodynamically unstable or wound up requiring operative intervention.
The authors support the following algorithm:
-With hemodynamically unstability children, obtain a pelvic XR
-For hemodynamically stable children when the physician is planning to get a CT, there is no indication for XR
Bottom line: Consider using AP pelvic radiographs in the hemodynamically stable patient with a high suspicion for fracture or dislocation who are not undergoing CT.
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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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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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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.