This was a retrospective study of 2700 infants < 3 months old who were evaluated for urinary tract infections (UTI).  The UTI prevalence in this group was 7.8%.  A UTI was defined as at least 50,000 colony forming units/mL from a catheterized specimen.  Test characteristics looked at white blood cell and leukocyte esterase cut-offs, dichotomized into specific gravities: dilute (<1.015) and concentrated (>/=1.015).

For respiratory distress and hypoxia: Infants have a lower FRC and can desaturate very quickly!

Supplemental O₂ should be delivered via face mask or nasal cannula or other devices such as high flow nasal cannula or nasopharyngeal CPAP, even if O₂ saturation levels appear normal with peripheral monitoring devices

For improved circulation: utilize peripheral IO early

Peripheral IV or IO access can be used for fluid resuscitation, inotrope infusion, and antibiotic delivery when central access is not readily available or obtainable

Initial therapeutic resuscitative end points: hypotension and poor capillary refill may portend imminent cardiovascular collapse!

• Capillary refill of < or = 2s
• Normalization of heart rate for age
• Normalization of blood pressure for age
• Lack of difference between central and peripheral pulses
• Warm extremities
• Urine output >1mL/kg/hr
• Normal level of consciousness

Antibiotics and source control: Early and aggressive source control is key, just as in adults!

• In up to 75% of pediatric sepsis cases, the underlying pathogen(s) remain unknown,
• A child’s immune system is incompletely formed, and they are markedly more susceptible to viruses and encapsulated bacteria
• Empiric antibiotics should be administered within 1 hour
• Blood cultures prior to antibiotics is preferred, but should not delay starting antibiotics
• Tailor antimicrobials to epidemic and endemic ecologies and consider resistant organisms
• Clindamycin and anti-toxin therapies for toxic shock syndromes with refractory hypotension
• C. diff. colitis should be treated with enteral antibiotics if possible, with vancomycin preferred in severe cases

Fluid resuscitation: Support the pump, and fill, but don’t overload the tank!

• Bolus 20 mL/kg fluid (isotonic crystalloid) IV/IO over 5-20min or faster if needed
• Repeat 20 mL/kg bolus of fluid (up to 60 mL/kg) until clinical symptoms improve or patient develops respiratory distress/rales/ hepatomegaly
• Titrate to reversing hypotension, increasing urine output, and attaining normal capillary refill, peripheral pulses, and level of consciousness
• If hepatomegaly or rales are present, consider early inotropic support and carefully titrated fluids
• Use diuretics to reverse fluid overload when shock has resolved, and if unsuccessful then CVVH or intermittent dialysis to prevent >10% total body weight fluid overload
• In non-hypotensive children with severe hemolytic anemia (i.e. severe malaria or sickle cell crisis) blood transfusion is considered superior to crystalloids
• Consider adrenal insufficiency in refractory shock and give hydrocortisone accordingly

Inotropes and vasopressors: not just Levo for all!

• Normotensive shock (impaired perfusion but normal blood pressure): Dopamine 2-20 mcg/kg/min IV/IO, titrate to desired effect; if continued poor perfusion, consider dobutamine infusion 2-20 mcg/kg/min IV/IO, titrate to desired effect (may cause hypotension, tachycardia)
• Warm shock (warm extremities, flash capillary refill): Norepinephrine 0.1-2 mcg/kg/min IV/IO infusion, titrate to desired effect
• Cold shock (cool extremities, delayed capillary refill): Epinephrine 0.1-1 mcg/kg/min IV/IO infusion, titrate to desired effect

Extracorporeal Membrane Oxygenation (ECMO)

Consider ECMO for refractory pediatric septic shock with respiratory failure – in kids, survival is improved dramatically – consider it early!

Blood products

• In hemodynamically unstable children in shock on pressors, hgb levels of ≥10 g/dL are targeted
• In stable critically ill children, a lower hgb target of ≥7.0 g/dL is recommended
• Similar platelet transfusion targets in children as in adults
• Consider plasma therapies in children to correct sepsis-induced thrombotic disorders
• IV immunoglobulin may also be considered

Mechanical ventilation

• If mechanical ventilation is required, then cardiovascular instability during intubation may be less likely after appropriate cardiovascular resuscitation
• Use lung-protective strategies during mechanical ventilation
• Sedation/analgesia is recommended in critically ill mechanically ventilated kids with sepsis

Glycemic control

• Watch for hypoglycemia (neonates < 45 mg/dL, infants/children < 60 mg/dL)
• Control hyperglycemia using similar targets as in adults < or = 180 mg/dL

Randolph AG & McCulloh RJ. Pediatric sepsis: important considerations for diagnosing and managing severe infections in infants, children, and adolescents. Virulence. 2014: 1;5(1):179-89. doi: 10.4161/viru.27045.

Wheeler DS, Wong HR, Zingarelli B. Pediatric Sepsis - Part I: "Children are not small adults!" Open Inflamm J. 2011: 7;4:4-15. doi: 10.2174/1875041901104010004.

Who- Mostly seen in children, but sometimes in immunocompromised adults

What- Peri-ungal infection of the fingerpad with pus-filled blister with erythematous base

Cause- May result from thumb or finger sucking. Staph and strep are the most common bugs, but it can be caused by MRSA.

DDx- herpetic whitlow, paronychia/felon, friction blister, insect bite

Treatment-

1. De-roof the blister

2. Send drainage for culture

3. Treat for staph and strep- no indication to treat for MRSA initially unless strong suspicion

4. 10 day course of antibiotics recommended

For additional information and image: http://www.medscape.com/viewarticle/718695_3

 

Diagnosis: Pathologic fracture with a unicameral bone cyst

Unicameral bone cysts are benign lesions that mainly affect children and adolescents.  On xray the cyst is noted to be a mildly expansile, lytic, thin walled lesion without periosteal reaction.  The most common sites are the proximal humerus and femur.  These lesions can resolve spontaneously, but there is a risk of pathologic fracture.  If fracture is detected, then the fracture site should be treated as any other fracture in the area.  These lesions can also be found incidentally in which case they should be referred to orthopedics for outpatient follow up.

Kadhim, M, Thacker M, Kadhim A and Holmes L.  Treatment of unicameral bone cyst: systemic review and meta analysis.  J Child Orthop.  2014 Mar; 8(2): 171-191.

Mascard E, Gomez-Brouchet A, Lambot K.  Bone cysts: Unicameral and aneurysmal bone cyst.  Orthop Traumatol Surg Res. 2015 Feb; 101.

 

Nail bed injuries occur in 15-24% of children with fingertip injuries.

In 1997, medical adhesive was first used to secure the avulsed nail plate back to the nail bed instead of suturing back into place.  By 2008, there were small studies looking at the utility of using medical adhesive to close the laceration of the nail bed.  The studies were small, but there was a tendency towards shorter repair times and no difference between pain, cosmetic outcome or function.

A total of 6 articles were included in this review – 2 using histoacryl and 4 using demabond.

Edwards, S, Parkinson L.  Is Fixing Pediatric Nail Bed Injuries with Medical Adhesives as Effective as Suturing?  A Review of the Literature.  Pediatric Emergency Care.  2016.

Tschudy MM, Arcara KM. The Harriet Lane Handbook 19th edition. Elsevier Mosby; 2012

80 children between 4 months and 6 years of age with fever > 101 degress F and watery stools (> 3 episodes) were evaluated for hydration status using urine samples.  The urine was collected either by catheterization or clean catch, depending on age.  All urine cultures were negative.

Nibhanipudi KV.  A Study to determine the Incidence of Urinary Tract Infections in Infants and Children Ages 4 months to 6 Years with Febrile Diarrhea.  Glob Pediatr Health. 2016. Published online Sept 12, 2016.

This was a small double-blind, prospective randomized controlled trial of 120 children with fluid-refractory septic shock in a PICU in Brazil. The primary outcome was to compare the effects of dopamine or epinephrine in severe sepsis on 28-day mortality; secondary outcomes were the rate of healthcare–associated infection, the need for other vasoactive drugs, and the multiple organ dysfunction score. Dopamine was associated with death (OR, 6.5; 95% CI, 1.1–37.8; p = 0.037) and healthcare–associated infection (odds ratio, 67.7; 95% CI, 5.0–910.8; p = 0.001). The use of epinephrine was associated with a survival odds ratio of 6.49. Further multicenter trials or single-center studeis are necessary to verify the reproducibiltiy of these results.

Ramaswamy KN, Singhi S, Jayashree M, Bansal A, Nallasamy K. Double-Blind Randomized Clinical Trial Comparing Dopamine and Epinephrine in Pediatric Fluid-Refractory Hypotensive Septic Shock.Pediatr Crit Care Med. 2016 Nov;17(11):e502-e512.

 

Kannikeswaran et al.  Optimal dosing of intravenous ketamine for procedural sedation in children in the ED – a randomized control trial.  American Journal of Emergency Medicine 24 (2016) 1347-1353.

1) Bradley et al. The Management of Community-Acquired Pneumonia in infants and children older than 3 months of age: Clinical Practice Guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin. Infect. Dis. 53:617-630 (2011)

2) Miller, S. How I treat acute chest syndrome in children with sickle cell disease. Blood 117:5297-5305 (2011)

3) Neumayr L, et al. Mycoplasma disease and acute chest syndrome in sickle cell disease. Pediatrics 1212:87-95 (2003)

This was a prospective randomized double blinded study in 8 pediatric emergency departments. Patients were at least 6 months old and younger than 11 years. To be included they had to have at least 3 episodes of vomiting or diarrhea in the previous 12 hours and a Gorelick score of at least 4. 100 children were included. Serum bicarbonate was measured at 0 and 4 hours and dehydration scores were reassessed. There was a change of bicarbonate of 1.6 mEq/L for plasma-lyte A (PLA) and no change for sodium chloride. There as an improvement in the dehydration score at 2 hours for the PLA group, but the dehydration scores were not statistically significant between the 2 groups at the 4 hours mark.

Allen et al. A randomized trial of Plasma-Lyte A and 0.9% sodium chloride in acute pediatric gastroenteritis. BMC Pediatrics 2016 16:117.

-Nickel allergy dermatitis is a type of allergic contact dermatitis common in skin tests in 8-16% of the pediatric population. Unlike irritant dermatitises (such as exposure to poison ivy), it usually takes repeated exposure over time to develop. In this case, the back of the button on a pair of blue jeans was the offending agent, though belt buckles, earrings, watches, piercings, and any other metal that touches skin can also cause a similar reaction. -The process is a delayed type hypersensitivity reaction mediated by T cells. Topical steroids can help clear up the rash, but the best treatment is to remove contact with the offending agent. One simple method is to apply clear nail polish to the back of the metal button or otherwise cover it with a piece of cloth. -Between 10 and 16 percent of blue jean buttons may contain nickel according to two studies. -Commercial test kits are available to help determine what metal components contain nickel -Known metal allergies should be communicated and documented as it can complicate orthopedic appliances or cardiac stents

1. T. Suneja, K. Flanagan and D. Glaser, "Blue-jean button nickel; prevalence and prevention of its release from buttons," Dermatitis, vol. 18, no. 4, pp. 208-211, December 2007 .

2. T. Byer and D. Morrell, "Periumbilical Allergic Contact Dermatitis: Blue Jeans or Belt Buckles?," Pediatric Dermatology, vol. 21, no. 3, pp. 223-226, May-June 2004.

3. J. Brasch and J. Geier, "Patch Test REsults in Schoolchildren. Results from the Information Netowrk of Departments of Dermatology (IVDK) and the German Contact Dermatitis Group (DKG)," Contact Dermatitis, vol. 37, pp. 286-93, 1997.

4. W. Weston, J. Weston and J. Kinoshita, "Prevalence of Positive Epicutaneous Tests Among Infants, Children, and Adolescents," Pediatrics, vol. 78, pp. 1070-1074, 1986.

 

Jacob R, Bentur L, Brik R, Shavit I and Hakim F. Is capnometry helpful in children with bronchiolitis? Respir Med 2016; 113:37-41.

Inhaled nitrous oxide gas (N2O) or laughing gas, has a long history of use as anesthetics in dental and medical procedures, and can be used as a single agent for brief pediatric procedures. It has a short half-life of 5 minutes and is eliminated essentially non-metabolized through respirations.

Inhaled N2O has analgesic, anxiolytic, and amnestic properties. The mechanism of analgesia is hypothesized to be similar to that of opioids. Anxiolytic and sedative effect is similar to benzodiazepines and may involve GABA receptors.

The N2O is typically given as a mixture of 30% N2O with 70% O2, although 50:50 mixture is also safe. In the ED, it is usually given as monotherapy, as this meets criteria for minimal sedation. Nitrous oxide concentrations > 50% meet criteria for moderate sedation.

Complications are rare (most commonly, nausea/vomiting). Persistent use or abuse can be habit forming and has been associated with anemia and B12 deficiency. Rare side effects include asthma exacerbation, coughing, laryngospasm, cardiac events, and seizures. High nitrous concentrations can cause hypoxia and asphyxiation if sufficient oxygen isn’t supplied (FiO2 < 25%).

Alai, A. Nitrous Oxide Administration. Medscape/emedicine. http://emedicine.medscape.com/article/1413427-overview#a1

Guideline for Monitoring and Management of Pediatric Patients During and After Sedation Diagnostic and Therapeutic Procedures. American Academy of Pediatrics. 2011

Clinical Policy: Critical Issues in the Sedation of Pediatric Patients in the Emergency Department. Annals of Emergency Medicine, 51(4):378-399 (2008)

Kasmire K, Rogers S and Sturm J. Trampoline Park and Home Trampoline Injuries. Pediatrics 2016: 138 (3).

1.      Harless J, Ramaiah R, Bhananker S. Pediatric airway management. Int J. Crit Illn Inj Sci. 2014;4(1):65-70.

2.      Varghese E, Kundu R. Does the Miller blade truly provide a better laryngoscopic view and intubating conditions than the Macintosh blade in small children? Paediatr Anaesth. 2014;24:825-829.

3.      Passi Y, Sathyamoorthy M, Lerman J, et al. Comparison of the laryngoscopy views with the size 1 Miller and Macintosh laryngoscope blades lifting the epiglottis or the base of the tongue in infants and children <2 yr. of age. Br J Anaesth. 2014;113(5):869-874. 

Bernstein HH and Kimberlin DW. Intranasal FluMISSED its target. AAP News. July 2016.

Chung J et al. Seasonal Effectiveness of Live Attenuated and Inactivated Influenza Virus. Pediatrics 2016: 137 (2).

Hypertension is defined as a systolic or diastolic blood pressure > 95% for age, sex and height based on repeated measurements. There is no numeric blood pressure cut of for defining hypertensive emergency in pediatrics. Use a reference book such as Harriet Lane Handbook to determine percentiles. The proper size BP cuff should be used: bladder width that is at least 40% of the arm circumference at the midpoint of the upper arm and a length that is 80-100% of the arm circumference.

Hypertensive crisis in children younger than 6 years may present with: irritability, feeding disturbance, vomiting, failure to thrive, seizure, altered mental status, or congestive heart failure.

Treatment in the Emergency Setting

-Lower the BP to < 95 percentile in children with HTN and no signs of end organ dysfunction

-Lower the BP to < 90 percentile in children with end organ dysfunction or co-morbid conditions

-Start with IV if able

-Few anti hypertensive medications have been studied adequately in children.

-The cited article has a table of antihypertensive medications with doses to be used in children, but only 4 have FDA approved labeling for pediatrics (hydralazine, fenoldopam, sodium nitroprusside and minoxidil)

Stein DR, Ferguson MA. Evaluation and treatment of hypertensive crisis in children. Integr Blood Press Control 2016; 9:49-58.

Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Clinical Practice Guideline. Pediatrics. 2016; 137 (5):e20160590.