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The Centers for Disease Control and Prevention recently released guidelines on the diagnosis and management of mild traumatic brain injury (mTBI**) among children. From 2005-2009, children made almost 3 million ED visits for mTBI. Based on a systemic review of the literature, the guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI.
Key Recommendations:
1. Do not routinely image patients to diagnose mTBI (utilize clinical decision rules to identify children at low risk and high risk for intracranial injury (ICI), e.g. PECARN)
2. Use validated, age-appropriate symptoms scales to diagnose mTBI
3. Assess evidence-based risk factors for prolonged recovery. No single factor is strongly predictive of outcome.
4. Provide patients with instructions on return to activity customized with their symptoms (see CDC Resources below)
5. Counsel patients to return gradually to non-sports activities after no more than 2-3 days of rest.
A wealth for information and tools for provder and families can be found at:
www.cdc.gov/HEADSUP (including evaluation forms and care plans for providers)
www.cdc.gov/traumaticbraininjury/PediatricmTBIGuideline.html
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- Migraine diagnosis should only be made after other serious intracranial diagnoses have been ruled out.
- Pediatric migraine is a difficult diagnosis to make before the age of 7 years, due to communication difficulties
- Avoid opiates and barbiturates. They have not proven to be effective, and have been shown to decrease the effectiveness of future triptan treatments.
- First line treatment for mild to moderate migraines is acetaminophen and/or NSAID's. The addition of caffeine, has been shown to potentiate the analgesic effects of both.
- First line treatment for moderate to severe migraines is triptans.
- Most pediatric migraines presenting to the ED, are severe migraines that have failed the above abortive home treatments and have persisted for 24+ hours. These patients often require intravenous therapy.
- Dopamine receptor antagonist, specifically Prochlorperazine, 0.15mg/kg, 10mg max, has demonstrated the greatest effectiveness. Consider administration with diphenhydramine, 1mg/kg, 50mg max to prevent dystonic reactions.
- Concomitant dexamethasone, 0.6mg/kg, 20mg max administration has been shown to decrease acute recurrence.
- If prochlorperazine fails, other alternatives include Sumatriptan, 5-20mg IN, 50-100mg PO and lidocaine, 0.5mL of 4% solution IN.
- IVF hydration, and reduction of light and sound stimuli may be helpful.
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Is there an association between pulmonary aspiration, vomiting or any serious adverse event and the preprocedural fasting time?
The odds ratio of any adverse event did not increase significantly with each additional hour of fasting duration for both solids and liquids.
The guidelines set by the American Society of Anesthesiology for fasting include a minimum of 2 hours for clear liquids, 4 hours for breast milk, 6 hours for formula and light meals and 8 hours for solid meals containing fatty foods or meat.
This was a secondary analysis of a multicenter prospective cohort study of children 0-18 years who received procedural sedation in 6 Canadian pediatric emergency departments from 2010-2015. 6183 children were included with 99.7% meeting ASA 1 or 2 categories. 2974 patients did not meet the American Society of Anesthesiology fasting guidelines for solids and 510 patients did not meet the fasting guidelines for liquids. The overall incidence of adverse events was 11.6%. There were no cases of pulmonary aspiration. There was a total of 717 adverse events. 315 events were vomiting. Oxygen and vomiting were the most common adverse events.
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Chest xrays (CXRs) may lead to longer length of stay, increased cost, unnecessary radiation exposure, and inappropriate antibiotic use.
CXR in asthma are indicated for:
-severe persistent respiratory distress, room air saturations <91%
- focal findings (localized rales, crackles, decreased breath sounds with or without a documented fever > 38.3) not improving on >11 hours of standard asthma therapy
- concern for pneumomediastinum or pneumothorax
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Abdominal pain in children can be just as frustrating as dizzy in the elderly. Your exam is targeted at quickly ruling out acute pathologies, but then what? The diagnosis is often functional gastrointestinal disorders, like the ever exciting constipation. Abdominal migraine (AM) is an additional entity to consider during your emergency department evaluation.
The following factors are often associated with AM:
- peak incidence at 7 years old
- paroxsymal, periumbilical abdominal pain lasting more than 1 hour
- family history of migraine
- episodes not otherwise explained by known pathology.
AM can be associated with headache, pallor, anorexia, photophobia, and fatigue. There are multiple theories on the pathogenesis, which can be found in the article cited below. If there is a known history, and the patient is presenting with an exacerbation, the treatment protocols for migraine headache may be employed with good success.
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Bottom Line:
AM is increasingly recognized as a source of recurrent abdominal pain in children. If other organic pathologies can be ruled out, this may be an important diagnosis to consider so your patient can get the appropriate follow up and outpatient management.
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- The rainy East coast spring has increased tick populations in endemic areas such as Maryland resulting in more tick bites.
- ED visits for known tick bites present acutely, often with parents bringing in the tick to be identified/tested.
- Routine serologic testing and antibiotic prophylaxis is not recommended after every tick bite.
- If an attached tick is engorged, identified as I. scapularis, and has been attached for >36 hours, then antibiotic prophylaxis for Lyme can be prescribed if started within 72 hours of tick removal in those patients > 8 years of age
- Prophylaxis: Single dose of doxycycline 4 mg/kg or 200mg max
- If early Lyme Disese is present in the form of the classic rash of Erythema migrans, then treatment is doxycycline, 4 mg/kg or 100mg max BID for patients > 8 years of age or amoxicillin 50 mg/kg per day divided TID with 500 mg max TID in those < 8 years of age for 14 days
- Serologic testing is false negative in the first month of testing, and unnecessary in the ED for acute presentations.
Children with diabetic ketoacidosis (DKA) may have brain injuries ranging from mild to severe. The debate over the contribution from intravenous fluids towards poor neurologic outcomes has been ongoing for decades.
PECARN's large multicenter randomized, controlled trial examined the effects of the rate of administration and the sodium chloride content of intravenous fluids on neurologic outcomes in children with diabetic ketoacidosis may finally put the controversy to rest. There was no difference on significant neurologic outcomes based on the rate (fast vs slow) or concentration (0.9% vs 0.45%) of IV fluid administration.
Clinically apparent brain injury occurred in 12 of 1389 episodes (0.9%) of children in DKA.
Any change in the mental or neurological status of the patient should be concerning for life threatening edema and should be treated with mannitol 1g/kg IV bolus or hypertonic saline (3%) 5-10 mL/kg IV over 30 minutes.
BOTTOM LINE:
"Neither the rate of administration nor the sodium chloride content of intravenous fluids significantly influenced neurologic outcomes in children with diabetic ketoacidosis"
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The rate of occult bacteremia in infants 3 months to 24 months with a temperature higher than 40.5C was slightly higher when compared to those with a temperature higher than 39C.
363 infants (3 months to 24 months) with a fever > 40.5C who were well appearing were evaluated in this study. 4 were diagnosed with occult bacteremia (1.1%). 3 of these were caused by S. pneumoniae and 2 were fully immunized.
A larger sample size is needed to see if reconditions to include empiric blood cultures on this subgroup of patients is warrented.
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Although conjuncitivitis outside of the neonatal period is commonly caused by viruses, there are times when antibiotics are warranted due to bacterial infections, such as conjuncitivits-otitis syndrome.
- up to 25% of patients with conjunctivitis have concurrent otitis media (even in the abscence of ear pain) and up to 73% of patients with purulent conjunctivitis
- Non-typeable H. influenzae is the most common recovered bacteria.
- For these patients, systemic (oral) antibiotics are recommended and the topical ophthalmic antibiotics are NOT necessary.
- Antibiotics should cover beta-lactamase producing organisms, e.g. high dose amoxicillin-clavulanic acid (45 mg/kg BID; 600 mg/5mL concentration which is formulated to have less clavulanic acid
Bottom line: Every patient with conjunctivitis should have an examination of his/her TMs, as your management may change.
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There were 180 battery ingestions over a 5 year period at two tertiary care children’s hospital. The median age was 3.8 years (0.7 to 18 years). The most common symptoms were abdominal pain (17%), and nausea and vomiting (14%). X-rays detected the location in 94% of patients.
Based on these patients, a treatment algorithm was developed (See attached). Prospective validation is needed.
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Nursemaid’s elbow is a common pediatric injury with peak incidence occurring between two and three years of age. It is a condition that typically arises from a sudden upward pull of the arm as an axial traction is placed on the forearm, and the radius is pulled through the annular ligament, resulting in subluxation of the radial head. Over the years, various maneuvers have been attempted, but the two most common are supination with flexion and hyperpronation. A 2017 Cochrane meta-analysis analyzed 8 trials specifically comparing supination with flexion versus hyperpronation. Data from those trials suggested that hyperpronation resulted in less failures at ?rst attempt than the supination-?exion, and although there was limited data, there was no obvious difference in adverse events or pain between the two techniques.
Bottom Line: There is likely a lower risk of failure with first attempt reduction with hyperpronation than with supination-flexion for nursemaid’s elbow.
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Unsuccessful lumbar punctures (LP) may lead to epidural hematoma (EH) formation at the site of needle insertion which may affect subsequent attempts and lead to no success or a grossly bloody sample. There is no standard definition of a traumatic LP based on CSF red blood cell counts. Gross blood may also be obtained by interrupting the vascular structures outside the spinal canal which would not result in EH formation.
This was a prospective study of children younger than 6 months who had an LP at a single children’s hospital. Post LP ultrasounds were completed by the investigating team and interpreted by a pediatric radiologist. 74 patients were included in the study. 31% of the patients had evidence of a post LP EH. 17% fully effaced the thecal sac which would likely preclude future success at that anatomic site. 25% of patients where the clinician did not feel there was a traumatic attempt had evidence of an EH.The study was not powered to determine the risk factors for EH formation. The study also did not look at any other consequences to EH.
Key points: Point of care ultrasound to evaluate EH and bleeding at the failed LP site my provide useful information for a location of subsequent attempts. Also US to evaluate for bleeding in the spinal canal may help with interpretation of the CSF when a large number of red blood cells are present.
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- Stevens-Johnsons like rash and mucositis
- Most common in children and adolescents, with a mean age of 12 years old
- More common in males than females, 2:1
- Prodromal symptoms of cough, fever, and malaise precede
- Mucositis far out of proportion to body rash, 90% vs 10%
- Mucositis is primarily oral > ocular > genital in distribution, and can be severe
- Body rash may involve palms and soles
- Complications: dehydration, GIB, epiglottitis, blindness, pericardial effusion
- Testing: PCR nasal wash/BAL; agglutination assays IgM/IgG
- Treatment: azithromycin and supportive care; occasionally steroids; rarely IVIG
- Unlike Stevens-Johnsons, prognosis is good.
Fluid overload (defined in this study as (fluid input-output)/weight)) is associated with longer hospital stays, longer treatment duration and oxygen use.
Bottom line: Treat dehydration appropriately but try not to over resuscitate the asthmatic. Further studies are needed before definitive recommendations are made.
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Patient: 11 month old with trouble breathing and color change after a family member sprayed air freshener. Symptoms have since resolved.
What are you concerned about in the attached xrays?
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Case: 5 year old presents to the ED with 2 weeks of fever. She has extensive cracked, bleeding lips and a rash on her hands and feet. She was recently diagnosed with “walking pneumonia” and hand, foot and mouth disease this week. Her pediatrician sent her in for further workup after she was found to have an elevated CRP on outpatient labs. A similar picture appears in the link below:
What's the diagnosis?
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Your patient is an18 months old female with intermittent abdominal pain for the last 4-5 days. She has history of constipation and soy allergy, seen at an outside hospital three days ago for the same. She had an xray and was discharged home with instructions for at home clean out with diagnosis of constipation.
Mother is bringing her to your ED because the pain is back. The laxatives helped somewhat, but her symptoms have returned. She reports that the patient cries spontaneously, lasting 1-2 minutes, then completely resolves. These episodes happen at multiple times during the day.
ROS: Decreased appetite and energy, but NO fevers, vomiting, diarrhea, bloody stool, abdominal distension, hematuria, or lethargy.
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Bottom line: Oral morphine was not superior to ibuprofen and both drugs decreased pain with no difference in efficacy. Morphine was associated with more adverse events.
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In addition to suspicion of NAT with traumatic brain injury and burns, remember these other high risk injuries and features:
- Duodenal injuries in children <4 y/o
- Frena injuries in non-ambulating children
- Proximal and midshaft humeral fractures > supracondylar fractures
- Any bruising on the trunk, ears, neck, or with larger size or pattern
- Delay in seeking care, inconsistent history, mechanism inconsistent with developmental age, and blame of a sibling or other child inflicting harm are all historical features also high risk.