Case:
A 10 year old presents to the local emergency department after playing with their sibling. The child was “tackled” from behind. A history and physical exam inform you that the child has been healthy until now with a completely uneventful childhood. They are normal, healthy body habitus and laying on their right side, a pillow between their flexed left knee & hip, and straight right leg. This is the only position of comfort for the child. Neurovascular exam is normal and the child refuses to let you move the leg at all. Foot and ankle move normally. Xrays were obtained promptly. A dislocated hip was readily identified (note the arrow sign below).
Greater than 85% of traumatic pediatric hip dislocations are posterior. Male children are at a greater risk by a 4:1 ratio, and in younger patients, they often occur with minimal force, whereas older children tend to require much greater forces due to the strength of structures surrounding the joint. Fractures can be an associated injury, though it was not in this case. A general triad to consider when evaluating for posterior dislocation is an adducted, shortened, and internally rotated leg as seen below:
Treatment:
A simple dislocation should be treated with closed reduction under sedation, ideally within six hours of injury to reduce the risk of osteonecrosis of the femoral head.
Reduction techniques:
There are many reduction techniques discussed in the literature. Most involve in-line traction of the femur with abduction and external rotation as the leg lengthens, with counter-traction (or downward pressure) placed on the pelvis. This allows for the femoral head to enter the acetabulum gently.
A quick review of technique with attending staff present on shift included the following three options:
The Allis maneuver (https://www.youtube.com/watch?v=zmk3vafjAd4): The physician stands on the stretcher with arms hooked under the flexed knee & hip (both at 90o) on the injured side and an assistant provides downward pressure on the pelvis. Hip extension and external rotation can be applied as the hip reduces.
2. The Captain Morgan technique (https://www.youtube.com/watch?v=lQMWaFX-MeQ&t=6s): The physician flexes the injured hip and knee to 90o and places their foot on the stretcher at the injured hip of the patient, their knee under the patients. They then grasp the patient’s leg with one hand under the popliteal fossa and one at the ankle. With counter-traction/downward pressure on the pelvis by an assistant, the physician plantar-flexes their foot to put traction on the patient’s femur. External rotation and abduction can be applied with the lower leg as the hip is reduced.
3. The cannon technique: The stretcher is raised and the patient’s knee and hip are flexed to 90o with the popliteal fossa sitting directly over the physician’s shoulder, hands on the patient’s ankle (while facing the patients feet). An assistant stabilizes and provides downward pressure on the pelvis. The physician slowly stands up straight providing in-line traction on the femur until the hip is reduced.
Case Conclusion:
Once x-rays confirmed a posterior hip dislocation, closed reduction under sedation in the emergency department was performed by a resident and staff physician using the cannon technique. Post-reduction films and repeat neurovascular exams were normal and follow-up with orthopedics was in place before discharge home.
Traumatic hip dislocation during childhood. A case report and review of the literature. American Journal of Orthopedics (Belle Mead, N.J.), 01 Sep 1996, 25(9):645-649
Big thanks to Dr. Paul Page for leading this month’s discussions
All cases are imaginary but highlight important learning points.
Case
You are working a day shift at a tertiary hospital that sees both adult and pediatric patients. You receive dispatch for a 2 year-old female with potential sepsis. Parents report high fevers for 4 days and poor intake. EMS report a somnolent child, febrile and tachycardic. ETA of 5 minutes.
On arrival the child appears mottled and drowsy, paramedics have placed a non-rebreather and are supporting the airway. You rapidly complete an assessment while the patient is being placed on cardiorespiratory monitoring and nurses attempt access. The patient responds to voice with whimpers. A paramedic is performing a jaw thrust while another bags. Breathing is shallow and rapid. She is mottled with cool extremities and delayed capillary refill.
Vitals: BP 60 SBP, HR 160 sinus tachycardia, T 39.7 RR 50 O2 88% on 100% NRB.
Gulp. You ask the nurse to page the pediatrician on call as you are worried about this patient.
Pediatric vitals are interpreted by weight or age, but you don’t need a table to see that these vitals are abnormal and this kid is altered. Frankly, this patient is pre-arrest if intervention doesn’t take place soon.
Not so sick kid? Here’s a reminder of expected vitals per age1.
Pediatric patients tend to compensate and compensate – until finally they don’t. Are there earlier signs of sepsis to be on alert for when assessing a patient1?
tachycardia out of proportion to fever – fever can give an expected increase in HR by 10 bpm,
tachypnea – RR tends to increase by 5 breaths/min for every 1 deg over 38°C.
poor perfusion – this can range from poor cap refill to altered level of consciousness.
When it’s later stages – it’s obvious. But sepsis doesn’t always have all these signs – a high suspicion is needed to recognize sepsis before it gets to critical stages.
What is the most concerning vital sign of our patient1?
Hypotension – this is a late sign of sepsis and if untreated the patient will arrest.
You suspect this child has septic shock given the brief history and temperature. Currently, their airway is being well managed by paramedics who have added NC under the mask and with continued jaw thrust they have improved oxygen saturation – but this is temporary.
You want to initiate management for sepsis and potentially need to intubate this child.
But before any of that can occur you need IV access.
Nurses have attempted twice and failed – it’s been 2 minutes. What next?
Do not hesitate to move to intraosseous (IO). This child may imminently arrest. Fluid resuscitation and administration of antibiotics are vital. If you can’t obtain IV access in 60 secs – obtain IO1
Preferred sites in pediatric patients (altered from EMdocs.net)2
Worried about hurting the child? Flush lidocaine through the IO – evidence suggests pain is more from infusions and medications through the IO than the insertion itself.1
Have more time with a relatively stable patient? Consider using PoCUS to help obtain peripheral lines
You obtain IO access and immediately request fluids. You want them to run in as fast as possible, but the child is too small for a level 1 infuser. What’s your approach?
First, choose the fluid type. Normal saline or Ringer’s lactate is fine to start. 20cc/kg is the typically starting bolus over the first 5 minutes of resuscitation. This can be repeated twice more up to 60cc/kg in the first hour. For this patient, and any patient under 2, load a 30-60cc syringe with crystalloid and manually bolus.
Signs of fluid overload?
Hepatomegaly and crackles auscultated in the lungs
A better sign – pulmonary edema seen on PoCUS3.
Normal vs B lines
IO assess has been obtained in both tibia, a nurse is pushing fluid manually while another asked you what antibiotics you want drawn up.
What are the broad-spectrum antibiotics suggested by age1?
You go back to reassess the patient’s airway. They are now satting 92% on 100% NRB + 5L NC. There is still some spontaneous whimpering. You estimate the GCS to be 9: E- 3 V- 2 M -4. This patient’s respiratory status is worsening and they have a low GCS. You feel they need intubation. Repeat vitals are obtained after first bolus.
BP 64 SBP, HR 158 sinus tach, T 39.8, RR 48 O2 as above.
Do you immediately intubate?
This patient is in profound shock, their catecholamine surge is deplete and any induction agents, even ketamine, would likely still worsen their hypotension and potentially precipitate arrest. If successfully intubated there is then the complication of increasing intrathoracic pressure – thus reducing blood flow back to the heart and decreasing cardiac output1.
The principle of resuscitate before you intubate is especially true in this situation.
You order repeat bolus of fluid to be manually given while antibiotics are being infused in the other IO. A nurse has now achieved peripheral IV access.
You prepare drugs and airway equipment for RSI – you plan to intubate once fluid boluses are complete if vitals have improved.
What drugs will you use? What drugs would you avoid5,6,7,8,9?
Avoiding worsening hypotension is key – ketamine is the drug of choice for sedation in children as it is considered hemodynamically neutral, but again expect drop in BP when the body is in shock. Ketamine also preserves airway reflexes and ventilatory drive.
Conversely propofol creates vasodilation and suppresses the myocardium – causing hypotension. It also can cause respiratory depression and apnea.
There is some evidence that etomidate is associated with less adverse events in septic patients, specifically hypotension. In one observational study in an adult population, ketamine was shown to be complicated by post-intubation hypotension more frequently when compared to etomidate.
In the pediatrics population etomidate for intubation in the ED setting has also been shown to be associated with minimal change in blood pressure – but this was a small, retrospective study. Currently etomidate is not recommended in patients < age 10 and more evidence is needed. One could also consider the potential for adrenal suppression post etomidate (etomidate inhibits functioning of an enzyme required to make cortisol, aldosterone and corticosterone). There are various studies – some in pediatric patients showing decreased plasma cortisol levels at 24 hours post etomidate. A similar effect was seen in other critically ill adult patients. The CORTICUS trial indicated a higher 28 day mortality in patients who received a single dose etomidate vs those that did not, regardless of being given exogeneous steroid.
For paralytics succinylcholine should be used cautiously in pediatric patients – it can precipitate hyperkalemia, bradycardia and even arrest. Rocuronium does have fewer side effects and contraindications, but it’s duration of action lasts approximately 50 mins – compared to approximately 6-10 minutes with succinylcholine. So strongly consider your choice – if you feel this is a ‘can’t intubate, can’t ventilate’ situation rocuronium is a dangerous choice.
You decide to go with ketamine and rocuronium and the drugs are being drawn up – what doses will you use?
In an adult population a safe choice in the shocked patient is to half the sedative and double the paralytic. The reason being even with ketamine you can get myocardial suppression and potential apnea.
For the paralytics use higher dose as the onset of action will be slower – double the dose.
For pediatric patients there is no evidence in the literature to support this practice, currently practice is to choose agents that have the least effect on hemodynamics – typically ketamine and rocuronium.
The RT is asking what size tube and airway equipment you would like.
Quick answer – Broslow tape. In this unstable patient this is the easiest way to get what you need without having to do any mental math. You request a cuffed tube – decreases the need for ET tube changes4.
While airway equipment is being set up you move now to prepare the patient. How do you position this 2 year old5,10?
Children have larger heads that naturally lies in flexion when supine. To align the mouth, larynx and trachea often the position has to be changed. You can roll up a towel to help with placement. As a rule of thumb:
Keeping a patient supine can also worsen hypoxemia as children have increased chest wall compliance and therefore increased work at baseline to maintain tidal volume. This can eventually lead to intrapulmonary shunting.
So although this patient doesn’t require additional positioning with a towel based on age we would still put the head of the bed up.
Someone asks if they can remove the additional oxygen mask or nasal cannula in preparation for intubation so it’s out of your way. Your response5?
No – pre-oxygenation is vital in the intubation of any patient, especially a child as they desaturate so quickly. In this 2 year old patient we expect a time of less than 4 minutes to desaturate to 90%. Children have much less surface area or ventilation channels as the alveoli continue to develop until the age of 8. In this patient with potential underlying respiratory illness there could be areas of atelectasis, worsening lung ventilation.
What other airway considerations are going through your head for a pediatric patient10?
Remember CHILD
For a great overall review see this infographic5
You are about to reassess the airway and obtain new vitals when the patient’s breathing changes to agonal and her whimpering has ceased. There is cardiac activity on the monitor, it be appears to be tachycardia with a widened QRS. Someone yells – check a pulse!
Do you need a pulse to initiate CPR in this patient?4
No – given the frequency of bradycardia and hypovolemia, pulse checks are not reliable. If apnea and unresponsive, initiate CPR.
At what rate should CPR be initiated in this patient4?
Use the encircling hands technique for infant CPR – it is shown to give better hemodynamics. Push hard (>1/3 AP diameter of chest) and fast (100-120 bpm), minimizing interruptions and allowing full recoil of the chest between compressions.
As this is an in-hospital cardiac arrest an LMA is immediately inserted to prevent interruption in compressions and to provide oxygenation.
Aim for 20-30 breaths/minute when an advanced airway is in place.
Out of hospital cardiac arrest4? Resuscitation with bag valve mask results in the same resuscitation outcomes as advanced airways -don’t underestimate the value of a good seal and a 2 person technique.
CPR is ongoing, an LMA has been inserted. The initial rhythm did not appear to be shockable. This is a PEA arrest.
What is your priority?
Determining the cause and in the meantime administering epinephrine – early administration within 5 minutes of non-shockable rhythms increases survival4.
You review your H’s and T’s.
You are pushing fluids for hypovolemia, the patient maintained oxygenation throughout with 2 sources of oxygen and had a normal oxygen saturation before arrest, the patient could be acidotic – but you are drawn to hypoglycemia. You rack your brain but can’t remember the glucose. You verbalize to the room, but no one knows if a glucose was done.
You quickly obtain one – 0.5.
You must correct glucose rapidly:
5cc/kg D10W IV push followed by an infusion of D10NS at 5cc/kg/hr (max at 250cc/hr)11
After the correction of glucose and additional round of CPR you get ROSC.
Obtaining a glucose is VITAL in any pediatric patient – something you know but failed to recognize as you had an unstable patient in front of you.
ABC + DEFG = ABC and DON’T EVER FORGET GLUCOSE1
What other metabolic abnormality must you consider1?
Hypocalcemia is commonly seen in critically ill pediatric patients, even without clinical signs like seizure or arrythmia it is recommended to treat.
Calcium gluconate 10% 0.5-1 cc/kg slowly over 5 minutes (max of 20 cc)
You reassess the vitals and the patient is still hypotensive and tachycardic despite 3 boluses and fluid circulating throughout the arrest. The oxygen saturation is 100%. The RT is still bagging via LMA. Clinically they appear cool and mottled with pulses weaker distally.
The patient is in cold shock. What is the vasopressor of choice11?
You initiate epinephrine at 0.05 mcg/kg/min IV and titrate up by 0.02 mcg/kg/min.
You assess cardiac function and lung fields via bedside ultrasound – the heart is hyperdynamic, lung fields are clear. You continue another bolus.
The patient’s GCS post arrest is back to 9. They are being easily bagged. You plan to wait until vitals have stabilized to switch out the tube.
At this point a pediatric attending arrives and you give an update.Immediately the staff begins verbalizing orders to the room for pressors, fluids and antibiotics. They begin questioning RT and direct them to intubate. The staff look to you for direction.
What do you do at this point?
This can be an uncomfortable situation to be in – this patient is still your patient; they are still unstable at this point and you have been guiding resuscitation. You have developed a sense of trust with your team and more than one leader can often lead to confusion.
You ask the attending to step out and together you review the management up to that point. This was a complex case with a lot of intervention. You discuss each medication given and the outcome. You make your suggestions on pressor support and fluid and reinforce what has been given. Together you are on the same page and go back in to reassess with the team.
It’s important to respectfully gain additional input from consultants and work together to ensure optimum care, but still realize that you are running the room. In other cases you may be at a loss for what to do and need guidance for what to do next – but again, once a plan is decided with your consultant it’s important that you verbalize to the room and give clear instruction to your team.
Overwhelmed and need to pass off? No problem – once you have help verbalize to the room that the consultant will now be leading resuscitation and stay nearby to assist and learn.
Lastly, what other medication should you consider if the patient’s hemodynamics or clinical picture do not improve1?
Steroid – up to 25% of pediatric patients with septic shock have adrenal insufficiency. This may be from the infectious process itself, from previous steroid use or from primary adrenal insufficiency.
You administer hydrocortisone 2mg/kg IV.
What markers of a successful resuscitation will you look for1?
Capillary refill < two seconds
Normal blood pressure
Normal pulses with no differential betweencentral and peripheral pulses
Warm extremities
Urine output > 1 ml/kg/hr
Normal mental status
Normal lactate
The patient gets admitted to the ICU for Pneumococcal sepsis and after a prolonged admission does well.
Pediatric patients are scary – use the resources you have, verbalize your thought process to the room and ask for help. Continuously reassess
ABC + DEFG = ABC and DON’T EVER FORGET GLUCOSE1
References and further reading:
EM Cases Digest – Vol 2. Pediatric Emergencies. Chapter 2: Sepsis and septic shock. Helmon, A. Lloyd, T. 2016. Toronto, ON.
Highlights of the 2020 American Heart Association Guidelines for CPR and ECC
Tolmie, A 2021. PEM Pearls01: Pediatric Airway Differences. CanadiEM. Retrieved Jan 20, 2022 from https://canadiem.org/pem-pearls-01-pediatric-airway-differences/
Mohr NM, Pape SG, Runde D, Kaji AH, Walls RM, Brown CA 3rd. Etomidate Use Is Associated With Less Hypotension Than Ketamine for Emergency Department Sepsis Intubations: A NEAR Cohort Study. Acad Emerg Med. 2020 Nov;27(11):1140-1149. doi: 10.1111/acem.14070. Epub 2020 Jul 20. PMID: 32602974; PMCID: PMC8711033.
Guldner G, Schultz J, Sexton P, Fortner C, Richmond M. Etomidate for rapid-sequence intubation in young children: hemodynamic effects and adverse events. Acad Emerg Med. 2003 Feb;10(2):134-9. doi: 10.1111/j.1553-2712.2003.tb00030.x. PMID: 12574010.
Sprung CL, Annane D, Keh D, Moreno R, Singer M, Freivogel K, Weiss YG, Benbenishty J, Kalenka A, Forst H, Laterre PF, Reinhart K, Cuthbertson BH, Payen D, Briegel J; CORTICUS Study Group. Hydrocortisone therapy for patients with septic shock. N Engl J Med. 2008 Jan 10;358(2):111-24. doi: 10.1056/NEJMoa071366. PMID: 18184957.
Big thanks to Dr. Joanna Middleton for leading this month’s discussions
All cases are imaginary but highlight important learning points.
Case:
A young mother presents to the ED with her 8 week old female. She noticed increased irritability and vomiting in the past 2 days. She describes her baby as generally ‘cranky’ but really didn’t notice any significant change until 2 days ago. She has 3 other children at home and describes her house as ‘chaotic’. She has difficulty tracking feeding patterns secondary to poor sleep but thinks her baby is feeding q5-6 hours. She thinks there are the same number of diapers, perhaps lighter. Her baby is formula fed and has always been ‘spitty’ but now she is vomiting non-bilious emesis. The vomiting is not related to feeds. She has been offering bottles more often since the vomiting started. She figured her baby caught something from one of her older children. She presented today as a family member stopped by and was concerned about the baby’s appearance.
On exam you see a pale, drowsy appearing baby. She opens her eyes to loud sound, cries weakly when handled, and withdraws from being touched. Her cap refill is delayed and her extremities feel cool to touch. Mucus membranes appear dry. Weight: 5 kg
Her vital signs: HR 182, RR 56 O2 97% RA. BP was not measured. Gluc 5.2.
GCS can be more challenging to calculate in younger pediatric patients. What is this patients’ Glasgow Coma Scale1?
You calculate the patient’s GCS to be 11 (E-3, V-3, M-5). With the elevated HR and RR you wonder if the decreased LOC is related to dehydration given the hx of vomiting. You quickly move the child to trauma and begin fluid resuscitation.
The learner with you asks if you feel the vomiting episodes are indeed related to a ‘gastro’ from an older child. Without a fever or hx of diarrhea you feel it’s less likely.
What are the causes of vomiting in the infant population?
After 1 month of age2:
Infections
Metabolic disorders including DM
Failure to thrive
Cow’s milk intolerance
Abuse
Intussception
Hirschsprungs
Gastroenteritis
Appendicitis
After an abdominal exam the learner can illicit no tenderness or peritoneal signs. There have been regular stools absent of mucus or blood, making Hirschungs and cow’s milk intolerance less likely. There have been no fevers to suggest infections. You have added a metabolic panel to the work up, but initial glucose at least was normal.
Your differential appears to be shrinking and one concerning diagnosis is moving to the forefront – abuse, something we don’t always consider with pediatric presentations.
What are some historical factors concerning for child abuse3?
Vague explanation or changing information
Explanation inconsistent with child’s physical or developmental abilities
Different witnesses give different explanations
Inadequate supervision resulting in injury
Delay in seeking medical care.
Certainly, this mother is not entirely sure of the progression of illness, but you figured it was due to sleep deprivation. Regardless, she presented today because a family member was quite concerned about the child’s drowsy state– something the mother failed to notice. This could potentially be a delay in seeking medical care.
You decide to further dive into the history with the mother.
What are some risk factors for child abuse3?
You determine that the mother is quite young and the biological father isn’t in the picture. She has 3 other children at home and her current boyfriend is the other adult living in the home. She had post-partum depression previously but feels this time around she only has ‘the blues’. She is unemployed and cares for the children, her boyfriend financially supports the family – he has not fathered any of her children. They met during her second trimester and quickly moved in together. She has one aunt who lives locally but otherwise very little support. When asked about her partner she is vague about how he makes a living and his role in the home other than financial support.
While you are getting a further history your resident is doing a more thorough physical exam on the infant.
What are physical exam findings concerning for abuse3?
Remember the 6 B’s
Bruises, Breaks, Bonks, Burns, Bites, Baby blues
BRUISES
Bruises– the most common abusive injury. Have a high suspicion if bruising is seen in an infant who is not mobile – over 50% of pre-mobile infants with bruising were victims of abuse.
Bruises in unusual places – follow the TEN-4 FACES Bruising Rule
Torso
Ears
Neck
Any bruise in a child younger than 4 months
Frenulum
Angle of jaw
Cheek
Eyelid
Subconjunctival Hemorrhage
* Highly suggestive of abuse
Patterned bruises
Hand prints or oval marks
Loop marks indicating rope, wire or electric cord
Linear bruises to buttocks indicating spanking, whipping or paddling
Belt marks
Linear bruising to the pinna
Retinal bleeding * present in 70-80% of children with abusive head injuries
Ligature marks
Burns
Multiple bruises
Compare with the shins as this is a bruise prone area on kids. More bruises than the shins? Concerning.
There is a new high-risk bruise screening pathway that may help identify occult injuries in the pediatric population. It involved identifying a concerning bruise in triage, which was any bruising in an infant <6 months or patterned bruising in age 6-48 months (ears, neck, torso). Overall, in this retrospective validation study high risk bruising pattern was rare, but they did identify occult fracture in 1/3rd of patient with high risk bruising <6 months of age4.
BREAKS
There is no pathognomic fracture for abuse, but fractures involve thorough history and physical exam. Fractures in young infants should trigger you into considering abuse.
Any fracture in a non ambulatory child
Femur fracture in an infant <12-18 months *19x greater odds of being consequence of abuse
Humerus fracture in an infant <12-18 months *32x greater odds of being a consequence of abuse
Multiple fractures or an unexpected healing fracture
Rib fractures – especially posterior, these have the highest probability for abuse
BONKS
Most skull fractures are accidental, but about 5% are non-accidental. Have a higher suspicion if complex, bilateral, depressed, open, occipital or presents with suture diathesis
BURNS
Accidental burns are usually scald injuries from spilling of hot liquids or touching hot surfaces, so expect injury to palm of hand or burns to anterior body with splash marks.
Concerning burns are usually immersion or contact
Immersion will often be stocking or glove distribution from forcing limbs into hot water, or the genital area from submersion in a tub.
Contact burns – look for well-demarcated areas like cigarette burns, iron, curling iron, etc.
BITES
Obvious teeth pattern
BABY BLUES
This refers to irritability in the patient, not the care giver. Irritability is a very non specific presentation so a thorough history and physical is vital.
The resident meets you outside the room after you finish the history to discuss the physical exam. They confirm the GCS of 11. Pupils appear to be 3mm and sluggish. There is evidence of retinal hemorrhage. They made note of bruising on the anterior chest and shoulder area bilaterally – it appears to be in the shape of fingerprints. Cardiovascular, respiratory, abdominal, and genitourinary exam are unremarkable. Limbs appears to be non-tender and have normal passive range of motion when examined. Other than the bruises mentioned, the skin appears pale and cool to the extremities. Fontanelles were noted to be bulging, instead of the expected sunken appearance one sees with dehydration.
Your suspect non-accidental trauma.
As irritability and vomiting are such common presentations in pediatric patients, is there a tool you can use to objectively determine if non-accidental head trauma should be higher up on your differential?
The Pittsburg Infant Brain Injury Score for Abusive Head Trauma5
This is a validated, clinical prediction rule to help physicians in deciding if an infant is high risk and should undergo a CT head to evaluate for abusive head trauma. The validation study included infants age 30-364 days who were well-appearing, afebrile, with no obvious history of trauma but who presented with a symptom associated with an increased risk of abusive head trauma.
Symptoms included:
ALTE/apnea
Vomitting without diarrhea (>4 episodes of vomiting in previous 24 hours or ≥3 episodes of vomiting per 24 hours in the past 48 hours)
Seizures/seizure like activity
Soft tissue swelling of scalp
Bruising
Other non-specific neurological sx: lethargy, fussy, poor feeding
Upon evaluation a 5 point scale was used
Abnormality on derm exam (signs of injury as reviewed above in 6 B’s) (2 points)
Age ≥ 3 months (1 point)
Head circumference > 85th percentile (1 point)
Hg < 112 g/L
A score of 2 has a sensitivity of 93.3% and a specificity of 53% for abnormal neuroimaging.
You reevaluate the patient and arrange urgent CT. Does this child require any other screening investigations3?
Screening for other occult injuries depends on age, with more intensive screening done at younger ages when the child cannot vocalize their injuries. As the child gets older investigations are no longer screening, but focused based on presentation.
Your CT confirms a subdural hematoma.
Any intracranial injury can be abusive in etiology but subdural hematomas are the most common.
Epidural hematomas are usually more associated with accidental injury.
What if you were at a rural hospital and wanted to confirm your suspicion of increased ICP in a fussy baby to add to your clinical picture?
PoCUS can evaluate for hydrocephalus, intracerebral hemorrhage or infectious causes of irritability or drowsiness in a pediatric patient with open fontanelles6.
There are only case reports of this being used in the emergency department setting. Subdural hematomas require a view of the superior sagittal sinus which is difficult to achieve. Infectious causes are less likely to seen as well and can have subtle findings.
If you are going to complete the scan, hydrocephalus would be the most useful and easiest scan to complete.
The scan –
Use a linear probe and place directly on the open anterior fontanelle – this allows you to see the brain in the coronal plane and sagittal plane6.
Coronal plane with marker towards patient right, sweeping anterior to posterior.
Sagittal plane with marker towards patient’s face and sweeping left to right
In a nutshell, findings of hydrocephalus include extra axial fluid and asymmetrical ventricles as seen below6
You urgently call neurosurgery for a consult and reevaluate the patient – they are still protecting their airway and have slightly improved vitals post fluid.
You now have to go and speak with the mother.
What are some approaches to having a discussion with the caregiver around concerns for physical abuse3?
“Be direct and professional. “As a physician, I worry when I see X, Y and Z and it makes me concerned that someone may have hurt your child.”
Refrain from being accusatory. “It’s not my role to say who hurt your child but it is my obligation to report my concern.”
Encourage the family to focus on the child. “Right now, we need to make sure that your child gets the medical care that he/she needs.”
Call for help. Discuss the case with social work, child protective services, a child abuse consultant (eg. SCAN team), and the primary care physician”
How do you approach documentation in a case of pediatric physical abuse3?
This chart will likely be reviewed if/when investigation takes place. Proper, detailed documentation is key.
“History
Who is providing the history
What, when, who
Use quotations to document exact statements from child and caregiver
Any pain that the child is experiencing
Activities that may affect forensic evidence recovery (eg. bathing)
Review of systems – changes in behaviour, non-specific symptoms
The usual (past medical history, social history, meds, allergies)
Physical Exam
Head-to-toe
Fully expose the child – this is a trauma patient
Describe, draw or even photograph any injuries
Impression
Summary statement
If comfortable, offer an interpretation of the findings in the context of the history”
Summary table of approach3
The patient went on to have a surgical evacuation of the hematoma and recovered. Appropriate services were contacted
Not every presentation will be this dramatic – up to 25% of patients with physical abuse have a sentinel injury. This is often a trivial minor injury missed by us a sign of abuse7. Bottom line – to catch it, we need to suspect it. Review old charts, do thorough examinations, assess for risk factors and recognize the 6B’s.
Helman, A, Coombs, C, Holland, A. Pediatric Physical Abuse Recognition and Management. Emergency Medicine Cases. March, 2018. https://emergencymedicinecases.com/pediatric-physical-abuse/. Accessed Nov 16, 2021.
Crumm CE, Brown ECB, Thomas-Smith S, Yu DTY, Metz JB, Feldman KW. Evaluation of an Emergency Department High-risk Bruising Screening Protocol. Pediatrics. 2021 Apr;147(4):e2020002444. doi: 10.1542/peds.2020-002444. Epub 2021 Mar 2. PMID: 33653877; PMCID: PMC8015159.
Berger RP, Fromkin J, Herman B, et al. Validation of the Pittsburgh Infant Brain Injury Score for Abusive Head Trauma. Pediatrics. 2016;138(1):e20153756
“My name is Mandy Peach and I am Emergency Physician at the Saint John Regional Hospital in Saint John, New Brunswick. I’m currently completing a PoCUS Fellowship and a pediatric rotation through the IWK Emergency Department in Halifax…….
What is the evidence for the use of PoCUS and diagnosing pediatric pneumonia. Well trained PoCUS Physicians can identify pneumonia with a sensitivity of 89% and a specificity of 94%, compared community-acquired pneumonia chest x-ray has a sensitivity of 69% and a specificity of 100%, if you see it great…. but what about early bacterial pneumonia and this case PoCUS has the upper hand, and if you consider consolidations behind the heart that can be visualized on PoCUS and obscured on chest x-ray – PoCUS 2 chest x-ray zero. So clearly it’s a useful tool to have when trying to differentiate between bacterial pneumonia that requires treatment and viral causes that would indicate conservative management. So how do we actually ultrasound the lungs…..the first step is to make the kid comfortable scan them in a position of comfort for example and their parents arms what the patient touch the ultrasound gel or the probe so it’s less of a scary thing maybe play their favourite music or YouTube video on the background or give them their favourite or snack do you want to choose a high frequency linear probe and scanning the longitudinal plane ……….”
Listen to the Podcast for some useful tips on performing and interpreting lung ultrasound in the pediatric population.
A spontaneous perforation of the esophagus that results from a sudden increase in intraesophageal pressure combined with negative intrathoracic pressure (eg, severe straining or vomiting) otherwise known as Effort Rupture.
Difficult diagnosis in first few hours due to nonspecific early symptoms. But, delayed diagnosis results in significant mortality. Diagnosis and surgery within 24 hours carries a 75% survival rate but drops to approximately 50% after a 24-hour delay and approximately 10% after 48 hours.
25 to 45 percent of patients have no clear history of vomiting, and those that do are often confusing with pain sometimes preceding vomiting due to coexisting pathologies e.g gastroenteritis, gastritis, pancreatitis etc.
Clinical manifestations — The clinical features of Boerhaave syndrome depend upon the location of the perforation (cervical, intrathoracic, or intra-abdominal), the degree of leakage, and the time elapsed since the injury occurred. Patients with Boerhaave syndrome often present with excruciating retrosternal chest pain due to an intrathoracic esophageal perforation. Although a history of severe retching and vomiting preceding the onset of pain has classically been associated with Boerhaave syndrome, approximately 25 to 45 percent of patients have no history of vomiting. Patients may have crepitus on palpation of the chest wall due to subcutaneous emphysema. In patients with mediastinal emphysema, mediastinal crackling with each heartbeat may be heard on auscultation especially if the patient is in the left lateral decubitus position (Hamman’s sign). However, these signs require at least an hour to develop after an esophageal perforation and even then are present in only a small proportion of patients. Within hours of the perforation, patients can develop odynophagia, dyspnea, and sepsis and have fever, tachypnea, tachycardia, cyanosis, and hypotension on physical examination. A pleural effusion may also be detected.
Patients with cervical perforations can present with neck pain, dysphagia or dysphonia. Patients may have tenderness to palpation of the sternocleidomastoid muscle and crepitation due to the presence of cervical subcutaneous emphysema.
Patients with an intra-abdominal perforation often report epigastric pain that may radiate to the shoulder. Patients may also report back pain and an inability to lie supine or present with an acute (surgical) abdomen. As with intrathoracic perforation, sepsis may rapidly develop within hours of presentation.
Laboratory findings — Laboratory evaluation may reveal a leukocytosis. While not part of the diagnostic workup for an esophageal perforation, pleural fluid collected during thoracentesis may contain undigested food, have a pH less than 6, or have an elevated salivary amylase level.
The diagnosis of Boerhaave syndrome should be suspected in patients with severe chest, neck, or upper abdominal pain after an episode of severe retching and vomiting or other causes of increased intrathoracic pressure and the presence of subcutaneous emphysema (crepitus) on physical exam.
While thoracic and cervical radiography can be supportive of the diagnosis, the diagnosis is established by contrast esophagram or computed tomography (CT) scan
Delayed diagnosis is associated with high mortality
Radiological signs develop over time, repeat imaging is often useful when considering this diagnosis
Neonatal Status Epilepticus
When an altered few-day-old baby is brought into the ED, other than requesting immediate pediatric support, opening PediStat on you phone and trying to keep calm – consider the causes of altered LOC in pediatrics – Think VITAMINS:
V – Vascular (e.g. arteriovenous malformation, systemic vasculitis)
I – Infection (e.g. meningoencephalitis, overwhelming alternate source of sepsis)
T – Toxins (e.g. environmental, medications, contaminated breast milk)
A – Accident/abuse (e.g. non-accidental trauma, sequelae of previous trauma)
M – Metabolic (e.g. hypoglycemia, DKA, thyroid disorders)
I – Intussusception (e.g. the somnolent variant of intussusception, with lethargy)
N – Neoplasm (e.g. sludge phenomenon, secondary sepsis, hypoglycemia from supply-demand mismatch)
S – Seizure (e.g. seizure and its variable presentation, especially subclinical status epilepticus)
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
