Dr. Victoria Landry iFMEM R3
Tag Archives: pediatrics
Vascular Access In Children: Solve the Puzzle
Dr. Rawan Alrashed (@rawalrashed)
PEM Physician
PoCUS Fellow
Reviewed and edited by: Dr. David Lewis
Background
Pediatric vascular access is one of the challenging skills in the medical field especially during an emergency, different guidelines have been established to facilitate the choice of the proper IV access one of which is the miniMAGIC that was published in 2020.1 Choosing the right access is crucial for success taking in consideration the urgency of access, patient safety, infused fluid characteristic to determine the right one especially with a peripheral IV catheter failure rate of 77% in the first attempt.2 Difficult intravenous Access score (DIVA) is one of the tool that can be used to evaluate the feasibility of a peripheral IV and accordingly, the best next step for IV line insertion where Subjects with a DIVA score of 4 or more were more than 50% likely to have failed intravenous placement on first attempt.3
Figure-1: DIVA score.4
Types of vascular access
- Peripheral IV catheters (PIVCS)
- Intraosseous Access
- Central Venous Catheters (CVCs) (Non-tunneled)
- US guided Access
- Umbilical Catheter
- Surgical cutdown
Figure 2: Vascular Access Locations.5
Consideration in pediatrics4
- Pain management is a critical step for the success of IV cannulation
Multiple choices are available starting from non-pharmacological distraction technique and non-nutritive sucking to the utilization of local anesthetic such as EMLA and LMX as well the needle-free lidocaine jet-injection
- Enhancing visualization of vein by using tourniquet, transilluminator with any available light source.
- Ultrasound guided peripheral IV access is the recommended current practice in difficult access.
- Ultrasound guided central IV access is the standard of care currently in comparison to anatomical landmark in critical care setting.
Indication of IV access
Patient resuscitation.
Delivering fluids, medication, Blood sampling.
Hemodynamics monitoring as well arterial blood gas.
Contraindications
Infection at the insertion site.
Thrombosis of the vein.
Bleeding diathesis in central line is a relative contraindication.
In IO Access, fracture on the same bone as well pathological disorder predisposing to fractures is a contraindication.
Peripheral IV catheter (PIVC)
Different veins can be used for PIVC starting with dorsal veins of the hand, then the feet and then proceeding to other choices including scalp vein in infants, external jugular vein, antecubital and the great saphenous vein as in Figure-2.5
Technique:5
- Prepare instruments: cleansing solution, tourniquet, catheter needle, connecting tube, flush, dressing, gauze, and stabilizer tape.
- Size of catheter as in the table: utilize the smallest gauge and shortest catheter as possible with exception in resuscitation where larger bore gauge is preferable or in case of midline cannulation where longer catheter is preferable.
- Apply tourniquet proximal to the site of insertion to enhance visualization
- Identify proper vein by visualization, palpation and utilizing the transilluminator or infrared light
- Clean the skin as per the facility protocol
- Hold the needle between the thumb and forefinger with the dominant hand and stretch the skin with the other hand
- Enter with an angle of 10-30 degree then if blood seen shallow your angle to advance 1-2 mm then advance the catheter and once in pull your needle or retract it.
- Flush to confirm patency and no swelling at the site then stabilize your catheter
|
Neonate | Infant | Children | Length |
PIV | 24-26G | 22G | 20G | 2-6cm |
Midline Access | 22G | 22G | 20G | 15-30cm |
Table-1: Size of PIV catheter.
US guided peripheral vascular access
A recent RCT by Vinograd et.al. evaluated 167 children showed 85% success rate of first attempt with US guidance compared to 45% with traditional methods. Also US guidance resulted in shorter cannulation time, less redirection and fewer attempts.6
Important consideration in US- guided PIV
- The diameter and depth of the vein have been found determinate factors for success of cannulation in adult studies where very superficial (< 0.3 cm) and very deep (> 1.5 cm) veins are difficult to cannulate.7
- The suggested veins are the cephalic vein in the forearm or the saphenous vein at the medial malleolus, while the antecubital vein might be an easy approach but the risk of brachial artery cannulation and the elbow bending make it less favorable. 7
Technique 7
- Use a linear probe with 5-15 MHz ( Alternatively a hockey stick or MicroConvex might be useful)
- Identify the vein and assess patency by being compressible and non pulsatile, for further confirmation utilize color or pulse wave doppler with augmentation to identify low status flow.
Longer catheter are preferable when using ultrasound guided insertion especially with a vein deeper then 0.5 cm to minimize the risk of dislodgment and infiltration (suggested to be longer than 2 cm). In a pilot study by Paladini, long catheter > 6 cm were associated with lower risk of failure in pediatric patients more than 10 years comparable to the short one <6 cm.8
- Static or dynamic guidance are acceptable with preference of the latter.
- Two approach technique available with best outcome observed with out-of-plane in PIVC.
Out-of-plane (Short-Axis):
- Consider using the middle point on the ultrasound machine to enhance alignment
- The US wave perpendicular at right angle to the vessel.
- The needle is inserted close to the probe at 20-30o angle then advance with meet and greet technique or dynamic needle tip positioning technique as in video
Pitfalls:
- The needle shaft might be misidentified as the needle tip thus the importance of advancing the probe then the needle to maintain visualization of the tip only. Also sweeping in the same plane can help to follow the needle proximal and distal to confirm the tip from the shaft.
- Risk of posterior wall penetration and failure of cannulation.
In-Plane (Long-Axis):
- The US beam is parallel to the vessel.
- The whole needle shaft is visualized during insertion and advancement to the vein.
- To facilitate visualization of needle “Ski left” technique can be used.
Pitfalls:
- Maintaining the transducer static without any movement is difficult in small children as any movement would lead to loss of needle visualization, thus insertion will not be accurate (side lobe artifact)
No evidence of preferable technique in pediatrics but in adults out-of-plane proven to be superior for PIVC insertion.
How to Use US for PIVC:
https://www.coreultrasound.com/ultrasound-guided-peripheral-iv-access/
Intraosseous Access
It’s considered the best alternative IV access in emergencies (peri-arrest and arrest condition) after 2 failed attempts of PIVC within 60-90 seconds, AHA recommends IO catheter as first line access in cardiac arrest. Still the outcome of out of hospital cardiac arrest and best access need more delineation.4,5
Technique4
- IO access can be accomplished using a manual needle or battery powered device such as EZ-IO or even a regular large bore needle.
- Place the knee in slight flexion with padding.
- Clean the skin and consider analgesia according to the urgency of the situation.
- Insert the needle at 900 over the skin.
- Remove the stylet and aspirate then infuse saline.
- Confirmation of proper insertion by the needle standing still even if no backflow seen with lack of extravasation during fluid infusion.
Figure-2 (on green) shows the possible site for IO insertion where the commonest one is the proximal tibial shaft about 1-2 cm from the tibial tuberosity avoiding the growth plate.
Complication4
- IO needle is a temporary access that can not last for more than 24 hours
- Longer use can predispose the child to complication including infection, thrombosis, fat embolism
- Other complications of insertion include through-and-through penetration of the bone, physeal plate injury, pressure necrosis of the skin, compartment syndrome, osteomyelitis, subcutaneous abscess
Confirmation of IO by POCUS2
- Use linear probe distal to the insertion site
- Apply color doppler and observe for saline flush site
- If above the bony cortical site or lateral or deep may indicate misplacement
Figure-3: POCUS confirmation of IO site.
Central IV Catheter (CIVC)
This an alternative longer duration route that can be utilized as an emergency line but less favorable compared to the IO during initial resuscitation. It is still considered a good choice in ill patients with difficulty of PIVC and failure of US guided peripheral access as well IO when fluid, high concentrated electrolytes and vasopressors are needed.4
The common site for insertion of non-tunneled CVC in pediatric is the internal jugular in critical care setting with higher success rate compared to femoral vein9 , but the femoral vein might be the first choice in PEM as it’s easily accessible and don’t interfere with resuscitation measures.10
Technique10
Always prepare your equipment and check them, also get consent when possible before attempting a central line
Age(years) | weight (kg) | Catheter gauge | French gauge | length (cm) |
<1y | 4-8 | 24 | 3 | 5-12 |
<1y | 5-10 | 22 | 3-3.5 | 5-12 |
1-3y | 10-15 | 20 | 4 | 5-15 |
3-8y | 15-30 | 18-20 | 4-5 | 5-25 |
>8y | 30-70 | 16-20 | 5-8 | 5-30 |
Table-2: CVC sizes.4
Anatomical Landmark5
Internal Jugular vein:
- Under aseptic technique with proper draping, put the patient in Trendelenburg position and turn the head slightly to the other side.
- Use the medial head of the sternocleidomastoid muscle or between the tow head at the level of the thyroid cartilage just lateral to the carotid artery guide your needle on a 45o toward the ipsilateral nipple while aspirating during insertion until you feel loss of resistance and have a backflow.
- follow with the guidewire into your needle and then dilator
- Complete by inserting the catheter line and fixing it.
Subclavian vein:
Directly below the clavicle at the junction of the lateral one third with the medial two third directing the needle toward the sternal notch
Femoral vein:
1-2 cm below the inguinal ligament medial to the femoral artery, guide the needle toward the umbilicus
US Guided CVC
The use of ultrasound guided insertion is considered the standard of care for central line insertion. Ultrasound use reduces the number of attempts and procedure duration, increases the successful insertion rate, and reduces complications compared to the skin surface anatomic landmarks technique.9
This can facilitate visualization, increase the success rate with 95% first attempt success rate of ultrasound-guided venous punctures compared to 34% of the anatomical landmark and decrease the rate of complication that would occur with the anatomical landmark.11
- Always start by identifying the land mark on US before starting the procedure (vein is compressible and less pulsatile than the adjacent artery)
- Probe position according to the site of insertion.
- Prepare the patient under aseptic technique as well the probe with sterile sheet and the ultrasound counsel unless you have assistance.
- Infiltrate local anesthesia to the skin puncture site.
- Utilize sterile gel on the outside of the sterile sheet or alternatively sterile water or saline
- Use an out of plane technique to guide the needle into the vein (higher success rate).
- Start by inserting the needle at 45 degree angle from the probe and the same distance away as the vein from the skin
- Follow the dynamic needle tip positioning technique (meet &greet) to keep visualizing the needle tip while guiding it toward the vein
- If confusing the needle tip with the shaft try to slide the probe proximal and distal until confirmation
- Use the same steps in aspirating while inserting until having a backflow and confirming the needle is inside the vein lumen
- Complete the steps as before and confirm the position of the guidewire by ultrasound.
- Insert the central catheter and fix it with sutures and transparent dressing.
Internal jugular vein:
Subclavian vein
Femoral vein
Complication12
Confirm proper placement by US as well X-Ray
R/O complication as pneumothorax, hemothorax or hematoma, mis-displacement
Artery puncture, air embolism, thoracic duct injury, arrhythmia are possible complications.
Umbilical Catheter
- Can be used in neonate up to 7 days old.
- Apply tourniquet to umbilical stump then cut the upper dried part.
- Identify the vein which is single and thin walled while arteries are two and thick wall.
- Stent the vessel with a forceps then insert the catheter up to 3-4 cm until blood return (Do NOT advance further as the risk of complication and adverse events are high)
Venous Cutdown
It is uncommon access in pediatric patients with the availability of IO needle, if needed the classic site is the saphenous vein which is 2 cm superior and anterior to the medial malleolus.
Resources:
- Ullman AJ, Bernstein SJ, Brown E, et al. The Michigan Appropriateness Guide for Intravenous Catheters in Pediatrics: miniMAGIC. Pediatrics. 2020;145(Suppl 3):S269-S284. doi:10.1542/peds.2019-3474I.
- Delacruz N, Malia L, Dessie A. Point-of-Care Ultrasound for the Evaluation and Management of Febrile Infants. Pediatr Emerg Care. 2021;37(12):e886-e892. doi:10.1097/PEC.0000000000002300.
- Yen K, Riegert A, Gorelick MH. Derivation of the DIVA score: a clinical prediction rule for the identification of children with difficult intravenous access. Pediatr Emerg Care. 2008;24(3):143-147. doi:10.1097/PEC.0b013e3181666f32.
- Whitney R, Langhan M. Vascular Access in Pediatric Patients in the Emergency Department: Types of Access, Indications, and Complications. Pediatr Emerg Med Pract. 2017;14(6):1-20.
- Naik VM, Mantha SSP, Rayani BK. Vascular access in children. Indian J Anaesth. 2019;63(9):737-745. doi:10.4103/ija.IJA_489_19.
- Vinograd AM, Chen AE, Woodford AL, et al. Ultrasonographic guidance to improve first-attempt success in children with predicted difficult intravenous access in the emergency department: a randomized controlled trial. Ann Emerg Med. 2019;74:19–27.
- Nakayama Y, Takeshita J, Nakajima Y, Shime N. Ultrasound-guided peripheral vascular catheterization in pediatric patients: a narrative review. Crit Care. 2020;24(1):592. Published 2020 Sep 30. doi:10.1186/s13054-020-03305-7.
- Paladini A, Chiaretti A, Sellasie KW, Pittiruti M, Vento G. Ultrasound-guided placement of long peripheral cannulas in children over the age of 10 years admitted to the emergency department: a pilot study. BMJ Paediatr Open. 2018;2(1):e000244. Published 2018 Mar 28. doi:10.1136/bmjpo-2017-000244.
- Pellegrini S, Rodríguez R, Lenz M, et al. Experience with ultrasound use in central venous catheterization (jugular-femoral) in pediatric patients in an intensive care unit. Arch Argent Pediatr. 2022;120(3):167-173. doi:10.5546/aap.2022.eng.167.
- Skippen P, Kissoon N. Ultrasound guidance for central vascular access in the pediatric emergency department. Pediatr Emerg Care. 2007;23(3):203-207. doi:10.1097/PEC.0b013e3180467780.
- De Souza TH, Brandão MB, Santos TM, Pereira RM, Nogueira RJ. Ultrasound guidance for internal jugular vein cannulation in PICU: a randomised controlled trial. Arch Dis Child. 2018; 103(10):952-6.
- Georgeades C, Rothstein AE, Plunk MR, Arendonk KV. Iatrogenic vascular trauma and complications of vascular access in children. Semin Pediatr Surg. 2021;30(6):151122. doi:10.1016/j.sempedsurg.2021.151122
A Seal Barking… In the ED?? – Croup Management in the Emergency Department
A Seal Barking… In the ED?? – Croup Management in the Emergency Department: A Medical Student Clinical Pearl
Kalpesh Hathi, CC3
MD Candidate, Class of 2023
Dalhousie Medicine New Brunswick
Reviewed by Dr. Jeremy Gross
Copyedited by Dr. Mandy Peach
All case histories are illustrative and not based on any individual.
Case Presentation:
You are the clinical clerk in the ED on a cold Monday, December afternoon. You pick up a chart that describes a 12-month-old baby boy, with a 1-day history of subjective fever of 38.4 C at its highest, respiratory distress, decreased PO intake and mom noting a barking cough.
Vitals: HR: 100 BPM, RR: 45, SpO2: 98% RA, BP: 90/65, Temp: 36.8 C, GCS 15, Wt: 10.2 kg.
You pull out your normal pediatrics vitals chart, and note that aside from a mildly elevated RR, these vitals are within normal limits for this child’s age and the child is afebrile.
What would you want to include in your history and physical?
History:
On history, mom says that the child began having classic URTI symptoms on Sunday (1 day ago) including a cough, rhinorrhea, and increased work of breathing. He also had a temperature of 38.4 C by ear on Sunday. Today, he began having what mom describes as increased work of breathing and a barking seal like cough.
Mom shows you two videos from this morning of the increased work of breathing and the barking-seal like cough:
Example of increased work of breathing (assume this is at home without the monitors attached):
https://www.youtube.com/watch?v=KQTEu1mpRY8&t=3s
As an astute clerk, you look for signs of increased work of breathing including tracheal tug, chest wall indrawing (inter, supra, or subcostal), abdominal breathing, grunting, head bobbing, cyanosis, nasal flaring, pursed lip breathing, and tachypnea.
Example of barking seal-like cough:
https://www.youtube.com/watch?v=UWOrKzgp3Wc
You agree that this sounds classically like a croup presentation.
The rest of the history including pregnancy, family, social, developmental, medications, allergies, and medical is largely unremarkable. The child’s vaccinations are up to date.
Mom is concerned as she feels the child is feeding and drinking less, but they are still having a normal number of wet (~6/day) and dirty (~1/day) diapers.
Physical Exam:
The child appears well in the ED, they are fussy and fighting your exam, they are jumping on the bed and playing with mom, they find comfort in mom, and they are even playing peek-a-boo with the RNs. You currently do not hear the barking seal like cough, nor stridor. They have mild intercostal indrawing, but no other signs of respiratory distress. No cyanosis is present.
Vitals are unchanged from the chart; the RR is still mildly elevated at ~40-45/min.
Resp: Mildly decreased air entry bilaterally, no crackles/wheezes. Mild stridor transmitted from upper respiratory tract upon agitation.
Fluid Status: Moist mucous membranes, fontanelles not bulging or sunken in, skin turgor is normal (no excessive tenting of skin), and when prompted they drink apple juice mixed with water.
You complete a thorough head to toe exam including HEENT, Neuro, Cardio, Abdo, GU, and MSK, aside from some cerumen in the ears and some rhinorrhea, the exam is within normal limits.
Differential Diagnosis [1-3]:
Croup
Bacterial tracheitis
Epiglottitis
COVID-19
Foreign body aspiration
Neoplasm
Hemangioma
Peritonsillar abscess
Retropharyngeal abscess
Acute anaphylaxis reaction
Bronchiolitis
- Bronchiolitis and lower respiratory tract infections would present with wheeze rather than stridor [1-3].
- Peritonsillar and retropharyngeal abscesses would have a hot potato voice, and potentially a mass on the neck [1-3].
- In children <6 months old it is important to consider congenital presentations such as choanal atresia and tracheoesophageal fistula [1-3].
- URTI symptoms would not be present in isolated foreign body aspiration but should be considered [1-3].
- It is important to differentiate croup from epiglottitis because epiglottitis can lead to rapid deterioration and often requires operating room intubation [1,2]. Drooling suggests epiglottitis whereas cough suggests croup, both have a high sensitivity and specificity for each respective diagnosis [1-3,4].
- Bacterial tracheitis the child would look much sicker and more toxic, and this would be represented on vital signs as well [1-3].
Croup:
Croup is a viral illness most commonly caused by parainfluenza virus, it is formally called laryngotracheobronchitis as it is inflammation of upper airway including the larynx, trachea, and bronchi [1,5].
Croup is a common presentation to Canadian emergency departments, most of which will be mild forms of croup, however occasionally hospitalization will be required, and rarely intubation is needed [1,6]
Classically croup will present in children between 6 months – 3 years old, with a 1-2 day history of URTI symptoms followed by a barking cough and stridor [1,7,8]. As this causes inflammation and obstruction of the upper respiratory tract, stridor will be present and often is more pronounced with agitation and at night [1,2]. A low-grade fever may be present, but is not required for the diagnosis, the child will not typically have drooling or dysphagia (if this is present consider epiglottitis) [1-3]. Parents will often be concerned/alarmed by the barking cough sounds.
As with most viral infections, croup is a self-limiting illness and most management is supportive, improvement should be noted within 2-7 days [1,6,7].
The diagnosis of croup is a clinical one of the child meeting the clinical picture outlined above and ruling out other causes with history and physical [1-3]. A radiograph is not needed to diagnose croup however if obtained due to uncertainty, will often show a narrowing of the glottic and subglottic areas in a classic steeple sign [3]. Whereas epiglottitis will show a thumb sign [9].
Picture taken from: https://www.pinterest.ca/pin/541980136386136007/
Picture taken from: https://kidshealth.org/Nemours/en/parents/az-croup.html
Workup of the Patient…
You remember some clinical decision aids for croup management… So, you employ the Westley Scoring System for Croup Severity [10]. As our child has a normal LOC, no cyanosis, stridor with agitation, mildly decreased air entry, and moderate retractions. They receive a Westley Score of 4 = moderate croup.
Mild </= 2
Moderate = 3-7
Severe = >/=8
Picture taken from: https://www.uptodate.com/contents/image/print?imageKey=PEDS%2F100744&topicKey=PEDS%2F6004&rank=1~60&source=see_link&search=croup&utdPopup=true
Based on this you pull out a trusted croup decision aid guide [1,11]:
Taken from: https://cps.ca/documents/position/acute-management-of-croup
In summary:
Mild croup, children will be given oral dexamethasone classically the dose is 0.6 mg/kg of body weight, however literature has shown equal effectiveness with 0.3 mg/kg, therefore some practitioners may opt for this lower in patients with moderate or mild croup [1,11,12]. Parents will be educated, and the child will be discharged home [1,11].
Moderate croup, the child will be given the same dose of dexamethasone and will be observed for 4 hours for improvement and sent home if symptoms have improved [1,11].
Severe croup, the child will be given blow-by O2 if cyanosis present, racemic epinephrine 2.25% (0.5 ml in 2.5 ml of normal saline) OR L-epinephrine 1:1000 5 mL, and the same dose of dexamethasone as above [1,11]. They will be observed for 2 hours and either sent home or admitted based on response [1,11].
Of note… previously aerosolized racemic epinephrine or L-epinephrine was given, however to reduce aerosolized treatments during the COVID-19 pandemic some emergency departments have received special authorization to give a puffer with epinephrine which was previously only approved in the US.
Case Conclusion
As our child had moderate croup and weighs 10.2 kg, they were given 0.3 mg/kg of dexamethasone which was 3.6 mg. We also performed a viral swab, which returns negative for COVID-19, but positive for parainfluenza virus, re-enforcing your diagnosis of croup. They were observed in the ED and quickly improved with no more increased work of breathing, and no stridor at rest. As such they were discharged to the care of their parents, and the parents’ received education on supportive management and indications to re-seek medical care. In fact, the SJRH ED has a handy parent information sheet that you give to the mother, which she is very appreciative of.
References:
- Ortiz-Alvarez O, Canadian Pediatric Society, Acute Care Committee. Acute management of croup in the emergency department. J Paediatr Child Health. 2017;22(3):166-9. https://cps.ca/documents/position/acute-management-of-croup#ref1
- Sizar O, Carr B. Croup. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK431070/
- Smith DK, McDermott AJ, Sullivan JF. Croup: Diagnosis and Management. Am Fam Physician. 2018;97(9):575-80. https://www.aafp.org/afp/2018/0501/p575.html
- Tibballs J, Watson T. Symptoms and signs differentiating croup and epiglottitis. J Paediatr Child Health. 2011;47(3):77-82. https://pubmed.ncbi.nlm.nih.gov/21091577/
- Rihkanen H, Rönkkö E, Nieminen T, et al. Respiratory viruses in laryngeal croup of young children. J Pediatr 2008;152(5):661–5. https://pubmed.ncbi.nlm.nih.gov/18410770/
- Rosychuk RJ, Klassen TP, Metes D, Voaklander DC, Senthilselvan A, Rowe BH. Croup presentations to emergency departments in Alberta, Canada: A large population-based study. Pediatr Pulmonol 2010;45(1):83–91. https://pubmed.ncbi.nlm.nih.gov/19953656/
- Johnson DW. Croup. BMJ Clin Evid. 2014. https://pubmed.ncbi.nlm.nih.gov/25263284/
- Bjornson CL, Johnson DW. Croup in children. CMAJ. 2013;185(15):1317-23. https://www.cmaj.ca/content/185/15/1317
- Takata, Fujikawa, Goto. Thumb sign: acute epiglottitis. BMJ Case Rep. 2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4904439/
- Yang WC, Lee J, Chen CY, Chang YJ, Wu HP. Westley score and clinical factors in predicting the outcome of croup in the pediatric emergency department. Pediatr Pulmonol. 2017;52(10):1329-34. https://pubmed.ncbi.nlm.nih.gov/28556543/
- Toward Optimized Practice. Diagnosis and Management of Croup. Clinical Practice Guideline, January 2008. www.topalbertadoctors.org/download/252/croup_guideline.pdf.
- Geelhoed GC, Macdonald WB. Oral dexamethasone in the treatment of croup: 0.15 mg/kg versus 0.3 mg/kg versus 0.6 mg/kg. Pediatr Pulmonol. 1995;20(6):362-8. https://pubmed.ncbi.nlm.nih.gov/8649915
Murmurs for the Learners: An approach to pediatric heart murmurs
Murmurs for the Learners: An approach to pediatric heart murmurs – A Medical Student Clinical Pearl
Luke MacLeod, Med IV
DMNB Class of 2022
Reviewed by Dr. Tushar Pishe
Copyedited by Dr. Mandy Peach
Case:
You are a senior medical student working in the emergency department and are asked to see Charlie, a 3-year-old boy who had a fall. He is accompanied by his uncle Kevin, who gives you the history. About one hour ago, Charlie was climbing onto a chair when he fell off and hit his head. The chair was only a few feet off the ground and the floor was covered with a rug. Charlie cried for several minutes after the fall, but there was no loss of consciousness or vomiting following the event.
Kevin tells you that Charlie is a healthy boy with no known medical issues or surgical history. There have been no concerns with his growth or development thus far. He has no allergies, does not take any medications, and is up to date on his immunizations. Kevin is unable to tell you much about Charlie’s family history. He recently adopted Charlie, whose biological parents are no longer involved.
On exam, you observe an active and responsive 3-year-old. He is afebrile with stable vital signs. He has normal colour and shows no signs of respiratory distress. There is a small bump on the top of his head, but no other injuries are noted. His neurological exam reveals no focal neurological deficits. To complete the exam, you feel his abdomen, which is soft and non-tender with no organomegaly, and auscultate his heart and lungs. His lungs are clear with no crackles or wheeze. On auscultation of the heart, you detect a soft, non-radiating systolic murmur that seems to go away with inspiration.
You are reassured from the history and exam that Charlie’s head injury was very minor and that no further investigations or interventions are necessary, but you wonder about the significance of his heart murmur.
What is a heart murmur?
A heart murmur is an additional sound, often described as whooshing or blowing noise, heard between heart beats that is generated by turbulent blood flow in or near the heart.1,2 Heart murmurs are very common, with up to 90% of children having one either during infancy or later in childhood. However, less than 1% of these murmurs are due to congenital heart disease.3 If the heart murmur is related to a serious underlying condition, the child may have signs or symptoms such as cyanosis, cough, shortness of breath, or light-headedness.1 Most murmurs are asymptomatic, but the absence of symptoms does not always mean that the murmur is benign.3 In some cases a murmur may be the only sign of an underlying heart condition.4
How to describe a murmur
Before picking up your stethoscope, you’ll want to make sure you have clean ear canals so you can pick up subtle murmurs. The characteristics use to describe a murmur can be remembered with the pneumonic Q-TIP ROLS (note: this is not a recommendation to clean your ears with cotton swabs).
Quality
The quality of a murmur can be described as harsh, blowing, musical, rumbling, or vibrating.3
Timing
Timing describes when the murmur occurs in the cardiac cycle. A systolic murmur occurs between S1 and S2. These can be further categorized into four sub-types:
- Early systolic: heard with or immediately after S1 and ends about halfway through systole.
- Mid-systolic/systolic ejection murmur: heard midway between S1 and S2. Increases then decreases in volume (crescendo-decrescendo).
- Mid-to-late systolic: heard about halfway through systole and ends before S2
- Holosystolic/pansystolic: heard throughout systole.
Click here to listen to a holosystolic murmur: https://www.youtube.com/watch?v=MzORJbyHTT0
A diastolic murmur occurs between S2 and S1. These can be further categorized into three sub-types:
- Early diastolic: a high-pitched murmur heard with or immediately after S2.
- Mid-diastolic: heard soon after S2 and ends before S1.
- Late diastolic/presystolic: heard just before S1.
A continuous murmur is heard throughout the cardiac cycle.3
Intensity
A grading system from 1-6 is used to describe a murmur’s intensity, with higher values representing greater volumes.3 The following table details what each grade indicates:5
Pitch
A murmur can have low, medium, or high pitch. High pitch murmurs are best detected using the diaphragm of the stethoscope, while low pitch murmurs are easier to hear using the bell.3
Radiation
This is the furthest point from the location (see below) where the murmur can still be detected.3
Other sounds
S3: heard in early diastole (shortly after S2). S3 can be present in hyperdynamic states or with a large VSD. This sound is best heard with the bell over the apex (for blood flow to the left ventricle) or the lower left sternal border (for blood flow to the right ventricle). When an S3 is present, the heart beat cadence is often described using the word “Kentucky” where “Ken” is S1, “tuc” is S2, and “ky” is S3.5
S4: heard late in diastole (just before S1) when there is turbulent blood flow into a stiff ventricle, such as in hypertrophic cardiomyopathy, myocardial dysfunction, semilunar valve stenosis, or tachycardia-induced cardiomyopathy. S4 is best heard with the bell and is a pathologic exam finding. When an S4 is present, the heart beat cadence is often described using the word “Tennessee,” where “Ten” is S4, “nes” is S1, and “see” is S2.5
Click below to listen to S3 and S4 heart sounds
https://www.youtube.com/watch?v=o8eqYHCy7dw
Ejection clicks
These are high pitch sounds that are often generated by abnormal heart valves. The affected valve is determined based on the location, timing, and nature of the click as shown in the table below:5
Pericardial friction rub
A coarse grinding sound heard with pericarditis. This is best heard along the left sternal border.5
Location
This is the point where the murmur is most easily heard.3
Shape
Shape describes a murmur’s volume pattern. A few examples are shown below:6
What are the characteristics of benign and pathological murmurs?
Some red flag characteristics of pathologic murmurs are listed below.4,7
- Holosystolic
- Diastolic
- Grade 3 or higher
- Harsh quality
- Systolic click
- Max intensity at upper left sternal border
- Abnormal S2
- Greater intensity with standing
Characteristics of benign murmurs can be remembered using The Seven S’s.4,8
- Systolic
- Soft
- Short (not holosystolic)
- Small (non-radiating)
- Sweet (not harsh)
- Single (no clicks or gallops)
- Sensitive (changes with position or respiration)
Click below to listen to an innocent heart murmur
https://www.youtube.com/watch?v=uFyWHPfrRak
Here are some examples to practice differentiating innocent from pathological murmurs:
https://teachingheartauscultation.com/pediatric-murmur-recognition-program-intro
What are some of the more common pediatric heart murmurs?
Innocent9
- Classic vibratory parasternal-precordial stills murmur
- Pulmonary ejection murmur
- Systolic murmur of pulmonary flow in neonates
- Venous hum
- Carotid bruit
Pathologic4
- Ventricular septal defect
- Atrial septal defect (example: https://www.youtube.com/watch?v=W8gg2S-mvSQ)
- Patent ductus arteriosus
- Teratology of Fallot
- Pulmonary stenosis
- Coarctation of the aorta
- Aortic stenosis
- Transposition of the great arteries
Next steps
In patients with a heart murmur and an abnormal chest X-ray or ECG, an echocardiogram is indicated. The echocardiogram is the gold standard test to diagnose congenital heart defects. While the chest X-ray and ECG are low cost tests and can help rule out other diagnoses, they are not particularly useful in identifying the cause of a heart murmur. 3
An innocent heart murmur in an asymptomatic patient with an otherwise normal exam does not require referral to cardiology. However, the patient should be followed by their family physician to monitor the murmur.
Patients who are symptomatic, have a pathologic murmur, and/or have other concerning exam findings should be referred to a pediatric cardiologist.10
Case Conclusion
Charlie’s heart murmur lacked any of the red flag characteristics. It was soft (grade 2) systolic murmur that did not radiate and changed with inspiration, which are all reassuring signs. He was also asymptomatic and had an otherwise normal exam.
You explain to Kevin that Charlie looks well and that there are no signs of serious head trauma. You mention that you did notice a heart murmur that is likely benign. Charlie does not need to see a specialist, but you recommend that he have a follow up appointment with his family doctor in the next few weeks to monitor the heart murmur.
References:
- Heart Pulse Sound Wave Icon Stock Vector – Illustration of blood, healthcare: 91331428. Accessed November 19, 2021. https://www.dreamstime.com/stock-illustration-heart-pulse-sound-wave-icon-background-image91331428
- Heart Murmur | NHLBI, NIH. Accessed November 18, 2021. https://www.nhlbi.nih.gov/health-topics/heart-murmur
- Heart murmurs: MedlinePlus Medical Encyclopedia. Accessed November 18, 2021. https://medlineplus.gov/ency/article/003266.htm
- Pediatric Heart Murmurs: Evaluation and management in primary care. Accessed November 18, 2021. https://oce-ovid-com.ezproxy.library.dal.ca/article/00006205-201103000-00006/HTML
- Frank JE, Jacobe KM. Evaluation and Management of Heart Murmurs in Children. Am Fam Physician. 2011;84(7):793-800.
- Approach to the infant or child with a cardiac murmur – UpToDate. Accessed November 18, 2021. https://www.uptodate.com/contents/approach-to-the-infant-or-child-with-a-cardiac-murmur?search=heart%20murmurs&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
- Physical Examination – Textbook of Cardiology. Accessed November 18, 2021. https://www.textbookofcardiology.org/wiki/Physical_Examination
- Pediatric Heart Murmur Recognition Program intro. Teaching Heart Auscultation to Health Professionals. Accessed November 19, 2021. https://teachingheartauscultation.com/pediatric-murmur-recognition-program-intro
- Bronzetti G, Corzani A. The Seven “S” Murmurs: an alliteration about innocent murmurs in cardiac auscultation. Clin Pediatr (Phila). 2010;49(7):713. doi:10.1177/0009922810365101
- Begic E, Begic Z. Accidental Heart Murmurs. Med Arch. 2017;71(4):284-287. doi:10.5455/medarh.2017.71.284-287
- McConnell ME, Adkins SB, Hannon DW. Heart murmurs in pediatric patients: When do you refer? Am Fam Physician. 1999;60(2):558-565.
Paediatric Supracondylar Fractures
Paediatric Supracondylar Fractures – A Medical Student Clinical Pearl
Reviewed by Dr. Joanna Middleton
Copyedited by Dr. Mandy Peach
Christine Crain (She/Her), CC3
Dalhousie Medicine MD Candidate, Class of 2022
Relevant Case:
On a Saturday, a three-year-old presented to the emergency department with his mother. He’d been playing in the backyard with his older sister who was on their swing. Unfortunately, the boy walked in front of the swing and was hit by his sister. He fell onto an outstretched hand and immediately began to cry and hold his elbow.
Problem:
There are two kinds of Supracondylar fracture; extension, which accounts for up to 95% of these fractures; and the far less common flexion fracture which occurs almost exclusively in older adults.
When a paediatric patient falls into an outstretched hand, the olecranon engages with the fossa, then acts as a fulcrum hyperextending the elbow, punching the olecranon through the relatively thin and weak supracondylar region of the humerus.
Figure 1: Case courtesy of Dr Samir Benoudina, Radiopaedia.org, rID: 39938
The Gartland classification (Fig.1) of supracondylar humeral fractures are based on the degree and direction of any displacement where Type 1 fractures imply little (1b) to no displacement (1a). Type 2 fractures displace the anterior humeral line (Fig.2) but leaves the posterior cortex intact; while type 3 fractures are completely displaced.
Figure 2: The anterior humeral line should pass through the middle third of the humeral capitulum. Case courtesy of Dr Samir Benoudina, Radiopaedia.org, rID: 41167.
Since these fractures commonly occur in children, learners especially need to be aware of the ossification centers within the elbow to be certain that they’re recognized as normal anatomy and not additional fractures. The age of the child should help you to estimate, with the help of a handy mnemonic, which ossifications centers should be visible on radiograph:
Figure 3: Case courtesy of Leonardo Lustosa, Radiopaedia.org, rID: 80555
In our case, with a three-year-old male, we would expect to see the Capitellum and Radial Head, but no other centers. We know any “fragments” in these areas are not additional fractures.
Most commonly in supracondylar fractures, there are other signs we look for that may indicate injury to the cartilage and forming bone:
- Sail Sign shows a joint effusion under the Anterior fat pad (Fig. 4)
- Posterior Fat Pad sign is the same, only on the posterior aspect of the elbow (Fig. 4)
- And, as noted above, the Anterior Humeral Line should intersect the middle third of the Capitellum (Fig. 2)
Figure 4: Showing both Anterior and Posterior fat pad sign. Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org, rID: 13527
Finally, given the number of vascular/neural structures that pass through the elbow, what complications are there to be aware of? As with all fractures, there is a risk of non/malunion, this is a relatively low risk however and is beyond the scope of this pearl.
Vascular complications include Volkmann’s contracture which can occur with injury to the brachial artery. This can result in a volar compartment syndrome leading to fibrosis and contracture of flexor muscles.
Finally, injury to any of the nerves that travel to innervate the hand/forearm can occur. Innervation through the Radial, Median (as well as the Anterior Interosseous nerve), and Ulnar nerves can be verified by a few quick and easy maneuvers as seen in Figure 5.
Figure 5: Innervation of the hand for the purposes of nerve injury screening.
Case Resolutions:
Inspection prior to radiographs showed intact sensation, brisk capillary refill with strong distal pulses, and ongoing ability to move joints below the injury. He was sent for radiographs which reported a supracondylar fracture. We casted his elbow and sent him for follow up to the Ortho fracture clinic the following week.
Conclusion
While learners may initially think ossification centers of the elbow are fracture fragments, using CRITOE they will be able to rule out joint involvement. This will allow you to move more quickly onto other radiographic signs of fracture.
References
- https://radiopaedia.org/articles/supracondylar-humeral-fracture-2
- https://radiopaedia.org/articles/gartland-classification-of-supracondylar-humeral-fractures
- https://radiopaedia.org/articles/anterior-humeral-line
- https://radiopaedia.org/articles/elbow-ossification-mnemonic
- https://radiopaedia.org/articles/sail-sign-elbow-1
- https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture–pediatric
Intussusception in the pediatric patient – SJRHEM Rounds December 2021
Dr. Brian Ramratten