Dr. Jaclyn LeBlanc, PharmD, MD, FRCPC
Infectious Disease Specialist
Dr. Jaclyn LeBlanc, PharmD, MD, FRCPC
Infectious Disease Specialist
Edited by Dr David Lewis
In a recent Lancet article (2017), PECARN, CATCH and CHALICE were compared.
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)
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.
PoCUS may have a role to play in fine tuning risk stratification and a recent study (2018) has further evaluated diagnostic accuracy:
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.
There is no definite evidence-based answer to this question. However this study suggest that 6 hrs is probably safe.
Treatment
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.
The management of fever in infants less than 1 month is relatively straightforward. Guidelines are generally consistent (Merck,
Emergency Medicine Cases article can be viewed here – Episode 48 – Pediatric Fever Without A Source
*********
For infants older than 30 days and younger than 3 months the guidelines are variable:
ALiEM: Paucis Verbis: Fever without a source (29 days-3 months old)
NICE Guidelines (UK): Fever in under 5s: assessment and initial management
MD Calc – Step-by-Step Approach Calculator
Suggested Emergency Department Approach
Yukon Guidelines
Differential Diagnosis (note: repetition is deliberate!)
No ‘rule’ is specific enough to correctly identify, so treat like VT
Treatment
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
Caveat – RRWCT (Regular Really Wide Complex Tachy)