• Pediatric visits for behavioral and mental health issues is on the rise.
• From 2008 to 2015, rates of PED visits for suicidal thoughts/attempts doubled.
• Shortage of pediatric psychiatrists:  8,300 nationwide with a need for 30,000.
• Deinstitionalized Movement of 1980's, has worsened this ED crisis-based culture.
• 50% of all mental illness begins by age 14.
• 1 in 5 children experience a mental disorder in a given year.
• Aggressive or agitated behavior in pediatric patients is different from adults.
• Children are more amenable to environmental and behavioral techniques, especially verbal de-escalation, once a trigger is identified.
• If not successful, avoid physical restraints and consider medications instead.
• Review current or previously prescribed medications, and consider extra/early/higher dosing. If naive to medications:
• First line is Diphenhydramine.
• Followed by Chlorpromazine, Risperidone, and Olanzapine
• Thorazine should be avoided in children under 12 years due to extra-pyramidal effects.
• Lorazapam not recommneded in children under 12 years, as it can cause disinhibition and worsen behavior.
• Avoid sedating children with neurodevelopmental disorders as they can have paradoxical reactions to diphenhydramine and benzodiazepines, and antipsychotics sometimes are not as effective.
• Boarding is common due to lack of resources, so starting treatment in the ED is imperative. 

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The hyperoxia-hyperventilation test (aka 100% Oxygen Challenge test) is used to differentiate the cause of central cyanosis in the sick neonate. The majority of neonatal cyanosis is caused by either cardiac or respiratory pathology.

Classically the test is performed as follows:

1. An ABG is obtained with the neonate breathing room air

2. The patient is placed on 100% FiO2 for 10 minutes

3. A repeat ABG is performed looking for an increase in PaO2 to >150 mmHg

 -   If the hypoxia is secondary to a respiratory cause, the PaO2 should increase to >150 mmHg.

-    If the hypoxia is secondary to a congenital cardiac lesion (i.e. secondary to a right-to-left cardiac shunt) the PaO2 is not expected to rise significantly. 

In practice, many physicians instead use pulse oximetry and monitor the SpO2 pre and post administration of 10 minutes of 100% FiO2.

-          If after 10min of 100% FiO2, if SpO2 is not ? 95% (some resources use 85%) then the central cyanosis is likely secondary to intracardiac shunt.

-          When this occurs, presume the sick neonate is symptomatic from a congenital cardiac lesion and initiate prostaglandin E-1 (PGE1) at 0.05-0.01 mcg/kg/min. Use caution as PGE1 may cause apnea.

Hyponatremia is the most common electrolyte abnormality in hospitalized patients, affecting approximately 15-30% of patients.  Children have historically been given hypotonic maintenance IV fluids based off of theoretical calculations from the 1950s.  Multiple studies have shown complications related to iatrogenic hyponatremia, including increased length of hospital stay, seizures and death.

The American Academy of pediatrics completed a systematic review and developed an updated clinical practice guideline:

Patient's age 28 days to 18 years requiring maintenance IV fluids should receive isotonic solutions with the appropriate amount KCl and dextrose.

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Post tonsillectomy hemorrhage occurs and 0.1-3% of post tonsillectomy patient's.  It occurs typically greater than 24 hours after surgery and up to 4-10 days postoperatively.  A survey of otolaryngologists showed that ED management strategies for active bleeding have included direct pressure, clot suction, silver nitrate, topical epinephrine, and thrombin powder.

This article was a case study demonstrating the use of nebulized tranexamic acid (TXA) for post tonsillectomy hemorrhage in a 3-year-old patient.  The patient had a copious amount of oral bleeding and had failed treatment with nebulized racemic epinephrine and direct pressure was not an option due to the patient's cooperation and small mouth.  250 mg of IV TXA was given via nebulizer with a flow rate of 8 L.  Bleeding stopped 5-7 minutes after completion of the nebulizer.  The patient was then taken to the OR for definitive management.  No adverse effects were noticed.

TXA in the pediatric population has been shown to decrease surgical blood loss and transfusions in cardiac, spine and craniofacial surgeries.  Studies have also been done in pediatric patients with diffuse alveolar hemorrhage using doses of 250 mg for children less than 25 kg and 500 mg for those who are greater than 25 kg.

Bottom line: There are case reports of nebulized TXA use in the pediatric population with no adverse outcomes noted.  More research is needed.

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Acute Disseminated Encephalomyelitis (ADEM) is primarily a pediatric disease and can cause a wide variety of neurologic symptoms. As such, should always be in the differential for pediatric patient presenting with vague neurologic symptoms including altered mental status. It is an immune-mediated, demyelinating disease that can affect any part of the CNS; usually preceding a viral illness or rarely, immunizations.

The average age of onset is 5-8 years of age with no gender predilection. It usually has a prodromal. That includes headache, fever, malaise, back pain etc. Neurological symptoms can vary and may present with ataxia, altered mental status, seizures, focal symptoms, behavioral changes or coma.

MRI is the primary modality to diagnose this condition. Other possible indicators may be mild pleocytosis with lymphocyte predominance, and elevated inflammatory markers such as ESR, CRP. These findings, however, are neither sensitive nor specific.

First-line treatment for ADEM is systemic corticosteroids, typically 20-30 mg/kg of methylprednisolone for 2-5 days, followed by oral prednisone 1-2 mg/kg for 1-2 weeks then 3-6-week taper. For steroid refractory cases, IVIG and plasmapheresis may be considered.

ADEM usually has a favorable long-term prognosis in the majority of patients. However, some may experience residual neurological deficits including ataxia, blindness, clumsiness, etc.

Take home points:

• Always keep ADEM on the differential for any pediatric patient presenting with any neurologic symptoms
• MRI is the diagnostic modality of choice.
• If ADEM diagnosed, start treatment early in conjunction with pediatric neurology.

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Historically uncuffed endotracheal tubes were used in children under the age of 8 years due to concerns for tracheal stenosis.  Advances in medicine and monitoring capabilities have resulted in this thinking becoming obsolete.  Research is being conducted that is showing the noninferiority of cuffed tubes compared to uncuffed tubes.  Multiple other studies are looking into the advantages of cuffed tubes compared to uncuffed tubes.

The referenced study is a meta-analysis of 6 studies which compared cuffed to uncuffed endotracheal tubes in pediatrics.  The pooled analysis showed that more patients needed tube changes when they initially had uncuffed tubes placed.  There was no difference in intubation duration, reintubation occurrence, post extubation stridor, or racemic epinephrine use between cuffed and uncuffed tubes.

Bottom line: There is no difference in the complication rate between cuffed and uncuffed endotracheal tubes, but uncuffed endotracheal tubes did need to be changed more frequently.

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• No matter what the school nurse says, only a temperature >/= 100.4 F or 38 C is a fever.
• Routine use of rectal and oral routes to measure temperature are not required to document a fever in children.
• Use of electronic thermometers in the axilla is acceptable even in children under 5 years
• Forehead chemical thermometers are unreliable.
• Reported parental perception of fever should be considered valid and taken seriously.
• Measure heart rate, respiratory rate, and capillary refill as part of the assessment of a child with fever.
• Heart rate typically increases by 10, and respiratory rate increases by 7 for each 1 C temperature increase.
• If the heart rate or capillary refill is abnormal in a child with fever, measure blood pressure.
• Do not use height of temperature to identify serious illness.
• Do not use duration of fever to predict serious illness.
• Tepid sponging/bathing, underessing, and over-wrapping are not recommended in fever.
• Do not give acetaminophen and ibuprofen simultaneously.

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Coins are the most commonly ingested foreign body in the pediatric age group with a peak occurrence in children less than 5 years old.  X-rays are considered the gold standard for definitive diagnosis and location of metallic foreign bodies.  This study aimed to find a way to decrease radiation exposure by using a metal detector.

19 patients ages 10 months to 14 years with 20 esophageal coins were enrolled in the study.  All proximal esophageal coins were detected by the metal detector.  5 patient's failed initial detection of the coin with the metal detector and all of those patients had the coin in the mid or distal esophagus with a depth greater than 7 cm from the skin.

Bottom line: A metal detector may detect proximal esophageal coins.  This may have a role in decreasing repeat x-rays.

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Historically, the C-reactive protein (CRP) has been used in the assessment of the febrile child and is the only biomarker recommended by the National Institute for Health and Care Excellence (NICE).

CRP increases 4-6 hours after the onset of inflammation, doubling every 8 hours and peaking at 36-50 hours.  It rapidly decreases once the inflammation has resolved.

An elevated CRP alone is not conclusive of a serious bacterial infection (SBI).

A CRP >75 mg/L increased the relative risk of SBI by 5.4.

A CRP <20 mg/L decreased the risk of SBI, but there was still a small subset of children where SBI was present.

In infants < 3 months initial CRP measurements are poorly accurate, but when trended may be useful in deciding when to stop antibiotics (rather then when to start them).  A normalizing CRP demonstrated a 100% negative predictive value for excluding invasive bacterial infection.

Bottom line:

CRP is not a rule in/rule out test

CRP is not helpful in diagnosing SBI, but serial measurements may be useful in monitoring response to treatment

CRP has a limited role in well appearing children older than 3 months

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Originally described a Dr. West in 1841 – it is a rare (~1200 cases annually)  seizure disorder in young kids, generally less than 1 year old.  Very subtle appearance, often with only bending forward or ‘jerking’ of the extremities as opposed to Brief Resolved Unexplained Event (BRUE) or tonic-clonic in description.  The spasms can be thought of as a syndrome, where 70% of those have an undiagnosed rare metabolic/genetic disease.

A prompt evaluation, including labs, EEG, MRI, metabolic and genetic studies is vital in helping to establish a diagnosis which can have a profound impact on the patients prognosis. Examples might include Tuberous Sclerosis, Pyridoxine Dependent Seizures among over 50 others.

Bottom line: In pediatric patients less than 1 year old who present to the Emergency Department with a description of spasm-like episodes, consider Infantile Spasms on the differential, and consult your friendly neighborhood Pediatric Neurologist for help in determining a proper disposition.

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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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