A 5 year old healthy boy, came to ED with history of limping since waking that morning. He had worsening right hip discomfort. No history of trauma. He had history of cold symptoms for the last 3 days associated with documented low grade fever.
On physical examination, he looked uncomfortable and unwell looking, he had temperature of 38.1 C, HR 130, BP 110/70, RR 20 and O2 saturation of 98% on RA. He was non-weight-bearing with decreased ROM of right hip because of pain.
Pelvis x-ray was unremarkable, he had WBC of 14.4 x 103 and CRP of 40 .
PoCUS of the right hip was performed.
Pediatric Hip Ultrasound
Ultrasonography is an excellent modality to evaluate pathologies in both the intra-articular and extra-articular soft tissues including muscles, tendons, and bursae. PoCUS to detect hip effusion can serve as an adjunct to the history and physical examination in case with hip pain. It is easily accessible, no radiation exposure and low cost.
Technique:
The child should be in supine position. Expose the hip with drapes for patient comfort. If the patient will tolerate it, position the leg in slight abduction and external rotation. A high frequency linear probe is the preferred transducer to scan the relatively superficial pediatric hip, use the curvilinear probe if increased depth is required.
With the patient lying supine, identify the greater trochanter on the symptomatic hip of the patient. Place the linear probe in the sagittal oblique plane parallel to the long axis of the femoral neck (with the indicator toward the patient’s head).
If the femoral neck cannot easily be found, it can be approached using the proximal femur. Place the probe transversely across the upper thigh. Identify the cortex of the proximal femur and then move the probe proximally until the femoral neck appears medially, then slightly rotate the probe and move medially to align in the long axis of the femoral neck.
Assistance is often required from a parent who may be asked to provide reassurance, apply the gel and help with positioning.
Both symptomatic and asymptomatic hips should be examined.
Negative hip ultrasound in a limping child should prompt examination of the knee and ankle joint (for effusion) and the tibia (for toddler’s fracture)
Hip X-ray should be performed to rule out other causes (depending on age – e.g. Perthes, Osteomyelitis, SCFE, Tumour). Limb X-ray should be performed if history of trauma or NAI.
Anatomy of the Pediatric Hip:
The ED Physician should readily identify the sonographic landmarks of the pediatric hip. These landmarks include the femoral head, epiphysis and neck, acetabulum, joint capsule and iliopsoas muscle and tendon.
A normal joint may have a small anechoic stripe (normal hypoechoic joint cartilage) between cortex and capsule. This will measure less than 2mm and be symmetrical between hips.
Ultrasound Findings:
Measure the maximal distance between the anterior surface of the femoral neck and the posterior surface of the iliopsoas muscle. An effusion will result in a larger anechoic stripe (>2mm) that takes on a lenticular shape as the capsule distends. Asymmetry between hips is confirmatory. Synovial thickening may also be visualized.
A capsular-synovial thickness of 5 mm measured at the concavity of the femoral neck, from the anterior surface of the femoral neck to the posterior surface of the iliopsoas muscle
OR a 2-mm difference compared to the asymptomatic contralateral hip
Right hip effusion, normal left hip, arrow heads – joint capsule, IP – iliopsoas
Interpretation
PoCUS has high sensitivity and specificity for pediatric hip effusion.
Sensitivity of 90%
Specificity of 100%
Positive predictive value of 100%
Negative predictive value of 92%
PoCUS cannot determine the cause of an effusion. It cannot differentiate between transient synovitis and septic arthritis. Diagnosis will be determined by combining history, pre-test probability, examination, inflammatory markers and PoCUS findings. If in doubt, septic arthritis is the primary differential diagnosis until proven otherwise.
Several clinical prediction algorithms have been proposed. This post from pedemmorsels.com outlines these nicely:
Ultrasonography cannot definitively distinguish between septic arthritis and transient synovitis, the ED physician’s concern for septic arthritis should be based on history, clinical suspicion and available laboratory findings.
The patient was diagnosed as case of septic arthritis. The patient received intravenous antibiotics empirically. Pediatric orthopedic consultation was obtained, and ED arthrocentesis was deferred as the patient was immediately taken to the operating room for hip joint aspiration and irrigation, confirming the diagnosis.
References
Tsung JW, Blaivas M. Emergency department diagnosis of pediatric hip effusion and guided arthrocentesis using point-of-care ultrasound. J. Emerg. Med. 2008;35(4):393-9.
Navarro OM, Parra DA. Pediatric musculoskeletal ultrasound. Ultrasound Clinics 2009;4(4):457-70.
Vieira RL, Levy JA. Bedside ultrasonography to identify hip effusions in pediatric patients. Ann Emerg Med. 2010;55(3) :284-9
Thanks to Dr. Andrew Lohoar and Sue Benjamin for leading the discussions this month
Major points of interest:
A) Intubated patients should not need restraints..
Post intubation sedation and analgesia can be challenging. Key is to avoid starting medications that could potentially drop blood pressure at very high infusion rates, but we need sedation and analgesia promptly.
Consider bolus of sedatives and analgesics prior to initiating infusions and prn boluses afterwards. Inadequate analgesia is often the cause of continued agitation.
B) But what about this guy with the BP of low / really low?
Consider “vitamin K” – ketamine – can augment BP in patients who are not catecholamine depleted.
C) Trauma patients you know will require consultants
When services are known to be required for patients prior to arrival (intubated, critical ortho injuries, penetrating trauma, transfers etc.) call a level A activation – consultants should meet patient with you. Give the consultants notice when patient is 15 minutes out.
Required consultants need to attend to critically injured in a timely fashion. Escalate to department head or chief of staff if there is unreasonable delay.
View the SJRHEM Trauma Page for list of definitions including Trauma Team, Activation Levels etc
E) Managing the pediatric airway – adrenalizing for all involved
Pediatric trauma is the pinnacle of a HALF (high acuity, low frequency) event. Team approach is key. Get out the Broselow tape.
Bradycardia with intubation attempts is not infrequent in youngest patients. Consider atropine as pre-med if < 1 year of age or < 5 years of age and using succinylcholine.
F) MTP
Do not forget platelets and plasma if onto 4th unit of PRBCs – 4:1:1 ratio.
G) Where is this patient being admitted?
Not to the hospitalist service, that is where!
Patients with significant injuries, but not needing immediate surgical intervention, should be admitted/observed in ICE x 24 hrs. Department head and/or chief of staff are available to assist if needed.
H) Chest tube types and sizes
Pigtail catheters for traumatic pneumothorax are effective, less painful and are gaining favour as an alternative to traditional chest tubes. As for sizes, there is likely little benefit for 36F over 32 F catheters – probably time to retire these monsters from the chest tube cart.
I) Why do bedside U/S if patient about to go to CT?
Chest scan might prompt chest tube placement prior to CT if pneumothorax is identified. Although identifying blood in the abdomen prior to CT may not change your management – it may prompt an earlier call to general surgery.
The secondary survey is performed once the primary survey and resuscitation has been completed.
The secondary survey does not begin until the primary survey (ABCDEs) is completed, resuscitative efforts are underway, and the normalization of vital functions has been demonstrated. When additional personnel are available, part of the secondary survey may be conducted while the other personnel attend to the primary survey. In this setting the conduction of the secondary survey should not interfere with the primary survey, which takes first priority. ATLS 9e
This means that on occasions trauma patients may be transferred to the OR or ICU before the secondary survey has been completed. The secondary survey is a thorough head to toe examination including where indicated adjunct investigations e.g limb radiographs. This assessment must be carefully performed and documented. It should not be rushed.
If there is not enough time to complete a thorough secondary survey (e.g patient transferred to OR during primary survey) then this should be communicated to the surgeon or other responsible physician (e.g ICU) and the documentation should reflect this.
We would recommend that all trauma patients admitted to the ICU undergo a repeat secondary survey assessment as part of the standard admission process. In some systems this is referred to as a Tertiary survey.
This systematic review reports a reduction missed injury rate when a tertiary survey is used as part of a trauma system.
The CMPA provides excellent guidance for clinicians considering Do Not Attempt Resuscitation orders. CMPA Website
CMPA – Key Concepts for End of Life Issues
The best interests of the patient are paramount.
The capable patient has the right to consent to or refuse medical treatment, including life-sustaining treatment.
Thoughtful and timely advance care planning, discussion, and documentation of a patient’s wishes and healthcare goals can help avoid misunderstandings.
Physicians should be familiar with any relevant laws and regulatory authority (College) policies concerning end-of-life care, and the withholding or withdrawing of life-sustaining treatment, and medical assistance in dying.
When considering placing a do-not-resuscitate order in the medical record, or acting upon a do-not-resuscitate order, consent from the patient or substitute decision-maker is advisable. It may also be helpful and appropriate to consult with physician colleagues and the patient’s family to determine support for the order.
Decisions about withholding or withdrawing life-sustaining treatment that is considered futile or not medically indicated should be discussed with the patient, or the substitute decision-maker on behalf of an incapable patient. When consensus is not achieved despite discussions with the substitute decision-maker, the family, and others such as ethics consultants, patient advocates, and spiritual advisors, it may be necessary to make an application to the court (or an administrative body) or seek intervention from the local public guardian’s office.
Physicians considering a request for medical assistance in dying should be familiar with the eligibility criteria set out in the Criminal Code, with applicable provincial legislation, and with applicable regulatory authority (College) guidelines.
Physicians should be familiar with the role of advance directives (including living wills).
End-of-life decisions should be carefully documented in the patient’s medical record.
Horizon Health, NB uses these accepted Canadian DNAR definitions:
The highest point validation sensitivities were shown for PECARN in children younger than 2 years (100·0%, 95% CI 90·7–100·0; 38 patients identified of 38 with outcome [38/38]) and PECARN in children 2 years and older (99·0%, 94·4–100·0; 97/98)
How do I use PECARN?
A useful review by EM Cases can be accessed here. In an update to this review they have noted recent new evidence that isolated vomiting without any other positive rule predictors may warrant observation only:
Update 2018: A secondary analysis of the Australasian Paediatric Head Injury Rule Study demonstrated head injury with isolated vomiting (i.e. vomiting without any of clinical decision rule predictors) was uncommonly associated with TBI on CT, or the presence of clinically important TBI. This study suggests a strategy of observation without head CT may be appropriate management. Abstract
Vomiting alone should not instigate CT. Risk goes up with any other Head Injury symptoms (Headache etc). These children should be observed until they are able to tolerate oral intake and the treating clinician feels comfortable that the patient is stable without additional symptoms of head injury.
This article discusses linear skull fractures. It reminds us to always consider Non-Accidental Injury in all cases of pediatric head injury, especially in the pre-mobile age group.
We enrolled a convenience sample of 115 of 151 (76.1%) eligible patients. Of the 115 enrolled, 88 (76.5%) had skull fractures. POCUS had a sensitivity of 80 of 88 (90.9%; 95% CI 82.9-96.0) and a specificity of 23 of 27 (85.2%; 95% CI 66.3-95.8) for identifying skull fractures.
If I don’t perform a CT, then how long should a child with a head injury be observed?
There is no definite evidence-based answer to this question. However this study suggest that 6 hrs is probably safe.
Key Points
Always use a clinical decision rule to determine whether a child with head injury requires CT, Observation or can be safely discharged
When using a decision rule utilize a ‘shared decision-making’ philosophy – i.e involve the parents/carers
A period of observation can reduce the number of CTs performed.
If observation is recommended, then allow 6hrs.
Always consider non-accidental injury during your assessment of pediatric head injury.
Clonazepam Toxicity
Overdosage of clonazepam may produce somnolence, confusion, ataxia, diminished reflexes, or coma
Clonazepam is extensively metabolized in the liver to several metabolites
Clonazepam is rapidly and well absorbed from the GI tract
Peak blood concentrations are reached in 2 -4 hours
Treatment is entirely supportive with IV access and fluids and maintenance of the airway and ventilation if required
Oral activated charcoal is of little value in pure benzodiazepine poisoning. It may be given to patients who have recently ingested benzodiazepines with other drugs that may benefit from decontamination
Flumazenil is rarely indicated except for iatrogenic oversedation or respiratory depression. In addition, flumazenil may cause withdrawal states and result in seizures, adrenergic stimulation, or autonomic instability in patients chronically taking benzodiazepine, or in those with ventricular dysrhythmias and seizures who are concomitantly using cocaine or tricyclic antidepressants.
Dispostion
All patients with intentional ingestion or significant ataxia, drowsiness, or respiratory depression should be observed.
Patients with severe symptoms (ie, coma, respiratory failure, or hypotension unresponsive to IV fluids) should be consulted to ICU.
Given the prolonged half-life patients strongly consider admitting patients who present with significant drowsiness or are known to have taken a large overdose.
Patients with a significant sedative drug overdose should be advised not to drive until potential interference with psychomotor performance has resolved. For significant benzodiazepine overdose, this is at least 24 hours after discharge.
Key Points
Clonazepam overdose is treated with supportive measures.
Clonazepam has a very long half-life. For significant drowsiness, admission should be considered to avoid potentially very long ED observation periods.
Pediatric (< 3 months) Fever
The management of fever in infants less than 1 month is relatively straightforward. Guidelines are generally consistent (Merck,
Full blood lab work-up (CBC, CRP, Cultures)
Urine culture
CXR
RSV, Flu nasal swabs
LP
Empiric IV Antibiotics (e.g Ampicillin 50mg/kg and Cefotaxime 50mg/kg)
Consult Pediatrics (Depending on results of above will either need admission +/- antibiotics or 24hr follow-up)
Yukon Guidelines
Wide Complex Tachycardia
Differential Diagnosis (note: repetition is deliberate!)
Ventricular Tachycardia
Ventricular Tachycardia
Ventricular Tachycardia
SVT with aberrant conduction – lots of causes
Pre-existing/rate-related BBB
Ventricular pre-excitation (AVNRT/AVRT)
Dysfunction of IV conduction system (toxic, metabolic, infectious, drug related etc) – hyper K, sodium channel blockers
No ‘rule’ is specific enough to correctly identify, so treat like VT
Treatment
Unstable?
ANY sign of end-organ dysfunction – hypotension, altered LOC, CHF/SOB, CP, diaphoretic etc
SHOCK
Stable?
Shock or medical management
Amiodarone vs procainamide, ?adenosine (see below)
Adenosine/vagal – consider in patients where uncertain of diagnosis, unlikely to be VT, no hx of CAD, young, hx of SVT
Adenosine with WPW – ContraIndicated – may induce AV block and accelerate conduction of atrial fibrillatory impulses through the bypass tract, which can lead to very rapid ventricular arrhythmias that degenerate to VF.
“Avoidance of IV beta blockers, calcium channel blockers and digoxin due to the potential for hemodynamic deterioration in patients with stable WCT, potentially resulting in hypotension, VF and cardiac arrest”. (Uptodate)
Verapamil and diltiazem are calcium channel blockers (CCBs) that should be avoided in WCTs, as cardiac arrests from hemodynamic collapse have been reported following their administration. Not only do these agents cause negative inotropy and at times profound vasodilation, but they may also allow WCTs to degenerate into VFIB
A 16 year old girl comes in by ambulance, after fainting while singing at church on a Sunday morning. Her vitals are: HR 90, RR 16, Temp 36.5, BP 92/64. O2 Sat 99% on RA. On arrival she is alert and looks well. She explains that she stood up to sing, felt lightheaded and then, soon after, lost consciousness. The paramedic lets you know witnesses say she turned ashen grey and sweaty, and was out for about 2 minutes. She had some ‘seizure like activity for 10 seconds’ with a few twitches in different parts of her body. The patient states she was fully recovered within a few minutes. Family history is unremarkable, with no sudden early deaths. Physical examination is also unremarkable. The nurse rolls in an ECG machine to check her rhythm.
What investigations does she require?
Why It Matters?
Pediatric syncope is very common in the emergency setting, accounting for ~1 % of pediatric emergency visits. Between 15 and 50% of children will have at least one syncopal event in their childhood (peaking in adolescence). – It’s a common problem!
The problem?
Historically, working up pediatric syncope has varied widely. ECG use has been routine and some centers have regularly ordered bloodwork, CTs and even EEGs. This onslaught of testing has led to increased hospital costs, stressful false positives for patients and has not improved patient outcomes. Plus, reading pediatric ECGs can be challenging – see the end of this pearl.
A potential solution
In 2017, the Canadian Cardiovascular Society and Canadian Pediatric Cardiology Association published a position statement on an approach to pediatric syncope¹ Full Article – click here
A thorough history and physical can be sufficient in low risk patients – no investigations are required for many pediatric syncope presentations.
Red flags
Lack of Prodrome: warm/clammy sensation, lightheaded ness, visual changes. Having a prodrome is the most important factor in benign syncope
Midexertional syncope; however post exertional syncope (having an opportunity to stop) is typically benign
Chest Pain preceding the event
Prolonged loss of consciousness
Family history of cardiovascular disease/sudden death
Palpitations are common in vasovagal events (although evidence around this not robust)
Involuntary movement is also common in vasovagal syncope. Benign movements can be a muscle twitch to violent jerks of the whole body
Investigative Algorithm
Figure 1. Pediatric syncope investigative algorithm, adapted from Sanatani et al. (2017)
The Evidence
To create this position statement, the Canadian Cardiovascular Society (CCS) performed a literature review of 4307 references, ultimately including 231 articles for full-text review.
Most of the studies referred to in the article are retrospective reviews. Therefore, recommendations in the position statement were mostly graded as ‘Strong recommendation, low level of evidence’. I found the most compelling evidence against routine ECG was the statement: “The ECG was the only indicator of cardiac disease in 5 of 480 patients (1%) and causality could not be determined”.¹ However, they did not list a reference for this statement and I’m not sure what study they drew this conclusion from. I do feel they make a compelling case against over investigation, but as in many areas of medicine, the evidence could be more robust.
Pediatric ECGs – how to interpret?
The nurse hands you the ECG, what features are worrisome on a pediatric ECG?
See following chart from the CCS¹
Figure 2. Pediatric ECG findings in syncope, adapted from Sanatani et al. (2017)
In summary, red light features should prompt an emergent cardiology referral. Yellow light features should prompt a non-urgent cardiology referral while green light features are normal variants and require no further work up.
Case Resolution
There were no red flags, arguably she requires no investigations, not even an ECG. Of course, clinical acumen trumps guidelines, but at least you will be CCS endorsed if you chose to not do any further investigations.
References
Sanatani, V. Chau, A. Fournier, A. Dixon, R. Blondin, R. Sheldon. Canadian Cardiovascular Society and Canadian Pediatric Cardiology Association Position Statement on the Approach to Syncope in the Pediatric Patient. Canadian Journal of Cardiology. 2017; 33: 189-198.
Urine is routinely analyzed and cultured as part of a sick child workup, as diagnosis of urinary tract infection can be difficult in pre-verbal children. They are unable to “point where it hurts”, and physical exam can be both difficult and unreliable in an irritable or obtunded infant. Urine may be collected in three ways – by “clean catch” collection, transurethral catheterization (TUC), and suprapubic aspiration (SPA). Given the inherent risk of contamination with local flora (over 25% in one cohort study)1, clean catch urine is typically useful only for ruling out UTI. TUC is more commonly performed as it does not require physician participation, but SPA remains a valid option for obtaining a urine sample for analysis and culture in children under the age of 2. It has been shown to have a significantly lower rate of contamination than TUC (1% versus 12%, respectively)1, although failure rates are higher with SPA4. Use of portable ultrasound has been shown to significantly increase the rate of success of SPA (79% US guided vs 52% blind)5.
Urinalysis/culture in children younger than 2 years
Chronic urethral/periurethral gland infection
Contraindications: 2,3
Genitourinary abnormalities (congenital or acquired)
Empty or unidentifiable bladder
Bladder tumor
Lower abdominal scarring
Overlying infection
Bleeding disorders
Organomegaly
Complications: 2,3
Gross hematuria
Abdominal wall cellulitis
Bowel perforation
Equipment: 2,3
Lidocaine for local anesthesia (1% or 2%, with or without epinephrine)
Adhesive bandaid
Povidone-iodine or Chlorhexidine prep
25g to 27g 1” needle
22g or 23g 1.5” needle
Sterile 5ml and 10ml syringes
Procedure (ultrasound-guided): 2,3
Position the patient supine in frog-leg position, using parent or caregiver to assist with immobilization.
Using sterile technique, identify the bladder on ultrasound; it appears as an anechoic ovoid structure just below the abdominal musculature.
Landmarking: midline lower abdomen, just above the pubic symphysis
Mark the area and sterilize; infiltrate local anesthetic into the marked area
Insert the needle slightly cephalad, 10-20° off perpendicular while aspirating until urine appears.
If the insertion is unsuccessful, do not withdraw the needle fully. Instead, pull back until the needle tip rests in the subcutaneous tissue and then redirect 10° in either direction. Do not attempt more than 3 times.
One sufficient urine is obtained, withdraw the needle and place a sterile dressing at the site of the insertion.
Contamination rates of different urine collection methods for the diagnosis of urinary tract infections in young children: an observational cohort study. Tosif S; Baker A; Oakley E; Donath S; Babl FE. J Paediatr Child Health. 2012; 48(8):659-64 (ISSN: 1440-1754). Retrieved from https://reference.medscape.com/medline/abstract/22537082 on December 10, 2017
Suprapubic Aspiration. Alexander D Tapper, MD, Chirag Dave, MD, Adam J Rosh, MD, Syed Mohammad Akbar Jafri, MD. Medscape. Updated: Mar 31, 2017. Retrieved from https://emedicine.medscape.com/article/82964-overview#a4 on December 10, 2017
Suprapubic Bladder Aspiration. Jennifer R. Marin, M.D., Nader Shaikh, M.D., Steven G. Docimo, M.D., Robert W. Hickey, M.D., and Alejandro Hoberman, M.D. N Engl J Med 2014; 371:e13September 4, 2014DOI: 10.1056/NEJMvcm1209888. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMvcm1209888 on December 10, 2017
Suprapubic bladder aspiration versus urethral catheterization in ill infants: success, efficiency and complication rates. Pollack CV Jr, Pollack ES, Andrew ME. Ann Emerg Med. 1994 Feb;23(2):225-30. Retrieved December 10, 2017.
Use of portable ultrasound to assist urine collection by suprapubic aspiration. Gochman RF1, Karasic RB, Heller MB. Ann Emerg Med. 1991 Jun;20(6):631-5. Retrieved December 10, 2017.
Sudden onset language impairment should be assumed to be aphasia until proven otherwise
Aphasia is most commonly caused by CVA and usually has associated lateralising motor signs (but not always)
Aphasic patients will be able to perform non-verbal tasks normally
If in doubt involve telestroke / neurology early
Global aphasia can have a catastrophic outcome on quality of life. In selected patients, early thrombolysis can significantly improve prognosis.
The injuries sustained by children in chest trauma are frequently different from adults
Signs of shock in pediatric trauma can be subtle
Use evidence based guidelines e.g PECARN when considering CT for abdominal trauma
Elevated Tropinin or abnormal ECG suggest blunt cardiac injury
Incomprehensible Patient – Delirium or Aphasia?
Both can present with disorders of speech and language, however it is important to rapidly distinguish aphasia due to it’s association with stroke and the benefits of early thrombolysis.
Delirium, also known as acute confusional state, is an organically caused decline from a previously baseline level of mental function. It often has a fluctuating course, attentional deficits, and disorganization of behaviour including speech and language.
Aphasia is an impairment of language, affecting the production or comprehension of speech and the ability to read or write. Aphasia is always due to injury to the brain, most commonly from a stroke, but also trauma, tumour or infection.
The first tip here is to figure out how to describe the features of a patient’s language. How is the patient’s language produced and understood?
Are the words clearly enunciated (favoring aphasia) or slurred (favoring delirium)?
Is the patient’s speech grammatically correct (delirium) or lacking in appropriate syntax (aphasia)?
Is the patient’s prosody—or pattern of speech—fluent (delirium) or irregular (aphasia)?
Can the patient understand spoken language (delirium) or is there a major difficulty with following simple verbal/written commands (aphasia)?
Naming and repetition should also be assessed as part of any neurologic examination, but impairment in these modalities is not as useful in distinguishing delirium from aphasia.
The motor evaluation of inattention in a delirious patient involves testing for asterixis, either with arms and wrists fully extended or having the patient squeeze the fingers of the examiner (the “milk maid’s sign”). A delirious patient will struggle with these tasks, the extended hands may flap or the fingers may intermittently lose their grip. The aphasic patient, in contrast, may not have trouble with this.
Severe impairment of production, comprehension and repetition of language
Usually large CVA of left MCA
Usually associated with extensive perisylvian injury affecting both Broca’s and Wernicke’s areas
Usually accompanied by right hemiparesis and often a right visual field deficit (in right handed pt)
Patients with global aphasia can be shown to perform normally on nonverbal tasks such as picture matching, demonstrating they are not suffering from confusion or dementia
Stroke Thrombolysis – Indications and Contraindications Reminder
Patient Selection for Thrombolytic Therapy in AIS:
Inclusion criteria: Patients >18 years of age with symptoms of AIS and a measurable neurological deficit with time of onset <4.5 h.
Exclusion criteria:
A. History
History of intracranial hemorrhage
Stroke, serious head injury or spinal trauma in the preceding 3 months
Recent major surgery, such as cardiac, thoracic, abdominal, or orthopedic in previous 14 days
Arterial puncture at a non-compressible site in the previous 7 days
Any other condition that could increase the risk of hemorrhage after rt-PA administration
B. Clinical
Symptoms suggestive of subarachnoid hemorrhage
Stroke symptoms due to another non-ischemic acute neurological condition such as seizure with post-ictal Todd’s paralysis or focal neurological signs due to severe hypo- or hyperglycemia
Hypertension refractory to antihypertensives such that target blood pressure <185/110 cannot be achieved
Suspected endocarditis
C. Laboratory
Blood glucose concentration below 2.7 mmol/L or above 22.2 mmol/L
Elevated activated partial-thromboplastin time (aPTT)
International Normalized Ratio (INR) greater than 1.7
Platelet count <100 x 109/L
Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated insensitive global coagulation tests (aPTT for dabigatran, INR for rivaroxaban) or a quantitative test of drug activity (Hemoclot® for dabigatran, specific anti-factor Xa activity assays for rivaroxaban, apixaban and edoxaban). In this situation, endovascular treatment (thrombectomy) should be considered if patient eligible.
D. CT or MRI Findings
Any hemorrhage on brain CT or MRI
CT showing early signs of extensive infarction (hypodensity more 1/3 of cerebral hemisphere), or a score of less than 5 on the Alberta Stroke Program Early CT Score [ASPECTS], or MRI showing an infarct volume greater than 150 cc on diffusion-weighted imaging.
Relative contraindications for rt-PA therapy in AIS include the following:
Recent myocardial infarction with suspected pericarditis
Rapidly improving stroke symptoms
Pregnancy or post-partum period
Recent GI or urinary tract hemorrhage (within 21 days)
Sudden onset language impairment should be assumed to be aphasia until proven otherwise
Aphasia is most commonly caused by CVA and usually has associated lateralising motor signs (but not always)
Aphasic patients will be able to perform non-verbal tasks normally
If in doubt involve telestroke / neurology early
Global aphasia can have a catastrophic outcome on quality of life. In selected patients, early thrombolysis can significantly improve prognosis.
Pediatric Trauma
Some specific issues particular to pediatric trauma are highlighted:
Pediatric Chest Trauma
Children have compliant chests and thus sustain musculoskeletal thoracic injuries far less frequently (5% of traumas). However, due to this elasticity, the most common injury is a pulmonary contusion.
PITFALLS
Don’t expect traditional adult injury findings: Absence of chest tenderness, crepitus and flail chests does not preclude injury.
Bendy ribs – injury to internal organs with little external evidence
Lung contusions ~50% of chest trauma
Force transmitted to lung parenchyma – lung lacerations much less common <2%
Pediatric Abdominal Trauma
Beware: 20-30% of pediatric trauma patients with a “normal” abdominal exam will have significant abdominal injuries on imaging.
Any polytrauma patient with hemodynamic instability should be considered to have a serious abdominal injury until proven otherwise. Tachycardia primary reflex for kids in response to hypovolemia and it may be the only sign of shock.
HIGH RISK – Indications for CT
• History that suggests severe intra-abdominal injury e.g abrupt acceleration/deceleration, pedestrian vs vehicle, handlebar injury, fall from horse etc
• Concerning physical – tenderness, peritoneal signs, seatbelt sign or other bruising
• AST >200 or ALT >125
• Decreasing Hb or Hct
• Gross hematuria
• Positive FAST
PECARN
The Pediatric Emergency Care Applied Research Network (PECARN) network derived a clinical prediction rule to identify children (median age, 11 years) with acute blunt torso trauma at very low risk for having intra-abdominal injuries (IAIs) that require acute intervention.
The prediction rule consisted of (in descending order of importance)
no evidence of abdominal wall trauma or seat belt sign
Glasgow Coma Scale score greater than 13
no abdominal tenderness
no evidence of thoracic wall trauma
no complaints of abdominal pain
no decreased breath sounds
no vomiting
The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15).
The clinical presentation of blunt cardiac injury varies. Mild injuries may present without objective findings, while some patients may have minor dysrhythmias.
A normal ECG and troponin I during the first 8 hours of hospital stay rules out blunt cardiac injury, and the negative predictive value of combining these 2 simple tests was 100%. https://www.ncbi.nlm.nih.gov/pubmed/12544898
Click image to link to full article
Traumatic Tricuspid Injuries
Location, location, location
RV posterior to sternum – blunt force elevates pressures resulting in rupture of chordae, papillary muscle injury or tear of leaflet
Most frequent associated injury: pulmonary contusion
“The presence of a transient right bundle branch block in the setting of myocardial contusion is a described, but under-recognized occurrence.”
“Although an rsr’ in the right precordial leads may be normal in children, it’s combination with an abnormal frontal axis (“bifasicular block”) is always abnormal and suggest injury to the RV”
The injuries sustained by children in chest trauma are frequently different from adults
Signs of shock in pediatric trauma can be subtle
Use evidence based guidelines e.g PECARN when considering CT for abdominal trauma
Elevated Tropinin or abnormal ECG suggest blunt cardiac injury
CME QUIZ
EM Reflections - Dec 17 - CME Quiz
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Quiz-summary
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EM Reflections – Dec 17 – CME Quiz
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Question 1 of 6
1. Question
Which of the following features suggests aphasia over confusion?
Correct
Certain features of a patient’s language can be helpful in differentiating confusion/delerium from aphasia. Clearly enunciated words that lack appropriate syntax and is irregular in speed, along with difficulty following simple verbal or written commands, all suggests aphasia. Delirious/confused patients can usually obey simple verbal or written commands and are more likely to have slurred speech that is grammatically correct.
Incorrect
Certain features of a patient’s language can be helpful in differentiating confusion/delerium from aphasia. Clearly enunciated words that lack appropriate syntax and is irregular in speed, along with difficulty following simple verbal or written commands, all suggests aphasia. Delirious/confused patients can usually obey simple verbal or written commands and are more likely to have slurred speech that is grammatically correct.
Question 2 of 6
2. Question
Which of the following defines global aphasia?
Correct
Global aphasia is the most severe form of aphasia and affects all aspects of language (fluency, repetition, comprehension, reading and writing). It is usually associated with a right-sided hemiparesis and is the result of a left MCA or carotid occlusion.
Incorrect
Global aphasia is the most severe form of aphasia and affects all aspects of language (fluency, repetition, comprehension, reading and writing). It is usually associated with a right-sided hemiparesis and is the result of a left MCA or carotid occlusion.
Question 3 of 6
3. Question
Which of the following is true about pediatric blunt chest trauma?
Correct
Kids have bendy ribs/compliant chests and as a result, pulmonary contusions are common and rib fractures not. Rib fractures in kids should be a red flag for significant mechanism of injury.
Incorrect
Kids have bendy ribs/compliant chests and as a result, pulmonary contusions are common and rib fractures not. Rib fractures in kids should be a red flag for significant mechanism of injury.
Question 4 of 6
4. Question
T/F – Liver function tests play an important role in pediatric trauma evaluation
Correct
most kids aren’t alcoholics, so even a small elevation of AST/ALT should raise concern for intra-abdominal injury. Consider CT in these patients.
Incorrect
most kids aren’t alcoholics, so even a small elevation of AST/ALT should raise concern for intra-abdominal injury. Consider CT in these patients.
Question 5 of 6
5. Question
T/F – Significant intra-abdominal injury is very unlikely in an alert, cooperative child who has no pain, a normal abdominal exam and a negative FAST
Correct
FAST does not rule out injury and 20-30% of kids with IAI will have a normal abdominal exam. Algorithms exist to help determine which patients should have a CT, e.g PECARN
Incorrect
FAST does not rule out injury and 20-30% of kids with IAI will have a normal abdominal exam. Algorithms exist to help determine which patients should have a CT, e.g PECARN
Question 6 of 6
6. Question
T/F – the risk of radiation from a CT scan should be the main consideration when deciding whether to scan a child with suspected intra-abdominal injury.
Correct
Use clinical decision tools to support decision to scan. The child will have to survive this injury to have any longterm risk of radiation induced malignancy!
Incorrect
Use clinical decision tools to support decision to scan. The child will have to survive this injury to have any longterm risk of radiation induced malignancy!
Jacqueline MacKay, R3 FMEM, Dalhousie University, Saint John, New Brunswick
The case:
A 16-month old girl with a history of fever of 39 degrees and slightly decreased oral intake for three days. She has no other symptoms of note and is a healthy, fully immunized child. Her vital signs are stable and her temperature is 37.9 after having some Advil at triage. After a careful head-to-toe examination, you note that she looks extremely well and you aren’t able identify a source for the infection.
Question:
Could this be a UTI? What investigations would be appropriate?
The overall prevalence of UTI in febrile infants age 2-24 months who have no apparent source for fever is 5%. There are some groups with higher than average risk of UTI and these groups can be identified. Additionally, the presence of another source of infection (based on clinical history and physical exam) reduces the likelihood of UTI by half.
Individual Risk Factors: Girls
Individual Risk Factors: Boys
Caucasian race
Age < 12 months
Temperature 39 degrees or greater
Fever for 2 or more days
Absence of another source of infection
Nonblack race
Temperature 39 degrees or greater
Fever for 24 hours or more
Absence of another source of infection
In girls age 2-24 months:
1 risk factor: probability of UTI 1% or less
2 risk factors: probability of UTI 2% or less
In boys age 2-24months:
uncircumcised: probability of UTI exceeds 1% even in the absence of other risk factors
circumcised with 2 risk factors: probability of UTI 1% or less
circumcised with 3 risk factors: probability of UTI 2% or less
The probability of UTI increases with the addition of more risk factors, and some of the factors (such as fever duration) may change during the course of the illness, increasing the probability of UTI.
Approximately half of clinicians consider a more than 1% risk of UTI sufficient for further investigation and treatment if UTI is found, to prevent spread of infection and renal scarring.
Recommendations:
If the clinician determines the febrile infant to have a low (<1%) likelihood of UTI, then clinical followup monitoring without testing is sufficient.
If the clinician determines that the febrile infant is not in a low risk group (>1% risk) then there are two options: obtain a urine specimen through catheterization or suprapubic aspirate for urinalysis and culture; or to obtain a urine specimen through the most convenient means and perform a urinalysis. If the urinalysis suggests UTI (positive leukocyte esterase or nitrites, or microscopic bacteria or leukocytes), then a urine specimen should be obtained through catheterization or suprapubic aspirate.
A negative urinalysis does NOT rule out UTI with certainty in children; however it is reasonable to monitor the clinical course without initiating antibiotics.
Urine from a specimen bag CANNOT be used for culture to document UTI due to high risk of contamination.
Case conclusion:
A bag specimen was obtained for urinalysis, which was negative. After discussion with the parents, no antibiotics were prescribed and close followup was available. The child’s fever resolved within 24 hours. The urine culture was also subsequently negative.
Reference:
American Academy of Pediatrics, Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement and Management; Roberts KB. Urinary tract infection: Clinical practice guideline for diagnosis and management of the initial UTI in febrile infants and children 2 to 24 months. Pediatrics 2011;128(
Volume Depletion (hypovolemia): refers to any condition in which the effective circulating volume is reduced. It can be produced by salt and water loss (as with vomiting, diarrhea, diuretics, bleeding, or third space sequestration) or by water loss alone (as with insensible water losses or diabetes insipidus).
Dehydration -refers to water loss alone. The clinical manifestation of dehydration is often hypernatremia. The elevation in serum sodium concentration, and therefore serum osmolality, pulls water out of the cells into the extracellular fluid.
Vertebral Artery Dissection – a tricky diagnosis and potentially catastrophic if missed…
Consider dissection in vertigo patients even without history of significant or mild trauma.
Headache and/or neck pain followed by vertigo or unilateral facial paresthesia is an important warning sign that may precede onset of stroke by several days. Dizziness, vertigo, double vision, ataxia, and dysarthria are common clinical features. Lateral medullary (Wallenberg syndrome) and cerebellar infarctions are the most common types of strokes.
Diagnosis – CT Angiography
Treatment – Antiplatelet or Anticoagulation (unless contraindications – see article below)
Cervical Artery Dissection in Stroke Study (CADISS) trial, RCT – antiplatelets versus anticoagulants in the treatment of extracranial carotid and vertebral artery dissections (VADs) = no difference found in outcomes between groups receiving antiplatelets vs anticoagulants. CADISS
Limping Kids – inability to weight bear is always significant…
Need for thorough investigation of non traumatic hip pain in child unable to weight bear. Don’t get biased with previous diagnosis even if by specialists.
Parents often give their children the wrong dose of medications.
Solution:
Provide parents a syringe to draw up medications
Describe the amount of medication in mL, not teaspoons or cc’s
Make sure to give simple instructions
Preamble:
It is well known amongst health practitioners that accurate dosing in pediatrics is extremely important; even a small miscalculation can have catastrophic results, potentially even death. We double check and triple check our calculations to make sure we prescribe the correct weight based dose. This is an excellent practice, and one we should continue to be diligent with, but if we don’t give proper instructions to parents, our calculations will be in vain: in a recent study of parents observed preparing prescriptions for their children, 84% of them made a measurement error!
In this randomized control study, 2110 parents were assigned to 5 different groups in an outpatient office setting. All groups got the same prescription for amoxicillin, and the parents were observed preparing the medication for their children (three times). The groups differed in the tools provided (measuring cup, syringe, or both) and how the units were described (mls, teaspoons or both). (See below).
Results:
Across all groups, 84.4% of parents made at least one measurement error (at least a 20% under/over dose). 21% of parents more than doubled the prescribed dose. The group with the fewest errors was group I: when prescriptions were only written in mLs, and only a syringe was provided. Using the measuring cup, 43% of parents made a dosing error compared to 16% with the syringes (p<0.001).
Parents with lower health literacy and from lower socioeconomic backgrounds were more likely to make mistakes, but like those with better literacy made fewer mistakes in the syringe only group versus the groups that included cups.
Conclusion:
When writing out pediatric liquid prescriptions, describe the medications in terms of mL and specify that the meds should be distributed with a syringe, or provide a syringe from the hospital. This study did not demonstrate whether having practice draw up medications reduced errors, however it seems prudent to have health care workers observe parents give a first dose in the ED if time permits.
YinHS, ParkerRM, SandersLM, et al. Liquid medication errors and dosing tools: a randomized controlled experiment [published online ahead of print September 12, 2016].Pediatrics. 2016; 138( 4): e20160357; doi: 10.1542/peds.2016-0357Abstract/FREE Full Text
