Tag Archives: pediatrics

Serum Sickness-Like Reaction

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Medical Student Pearl by Nicole Barry1 & Laura Harkness2

1. B.Sc., M.A., MD Candidate, Class of 2024, Memorial University

2.B.Sc., MD Candidate, Class of 2025, Dalhousie University

Reviewed by Dr. M McGraw & Dr. M Kovalik

Copy Edited by Dr. J Vonkeman

Pdf Download: EMSJ Serum Sickness-Like Reaction  NBarry & LHarkness

 

Case Overview 

History of Presenting Illness

A 5-year-old male arrives at the emergency department (ED) with his mother who is concerned her son is having an allergic reaction. She reported that the week prior, he presented to his family doctor’s office with general malaise and productive cough. He tested positive for Group A Streptococcal infection and was started on amoxicillin. The day prior to arriving at the ED, he developed a purpuric urticarial rash that covered his trunk and extremities which continued to progress. He complained of bilateral ankle pain and fatigue. The patient had no past medical history, was not on any other medications, his family history was unremarkable, and had no known allergies. There was no recent change in diet or environmental exposures.

Physical Exam

The patient had a temperature of 38.3 degrees. All other vital signs were normal. On exam, his gait was antalgic. His trunk and extremities had multiple large, erythematous, annular plaques. The lesions were pruritic, non-blistering, and non-photo sensitive (see Figure 1). His lips were erythematous, and cheeks appeared flush. His mucous membranes were spared. Head and neck exam was otherwise unremarkable. His ankles were swollen bilaterally, limited range of motion in all directions and non-tender to palpation. His knees were also swollen bilaterally, non-tender, positive patellar tap test. Wrist did not show signs of swelling, restricted motion, or pain.

Investigations

Based on the wheal-like rash, Lyme disease, Vasculitis and Kawasaki were ruled out. Reactive arthritis was unlikely with a lack of family history. Throat swab was collected to rule out post-streptococcal glomerulonephritis. Based on the age of the child, further blood work was held while throat swab was analyzed as to not cause distress. Renal function, CPR and Lyme anti-bodies may be indicated if the child was otherwise unwell with high degree of suspicious of a more severe diagnosis.

Diagnosis

Given the presentation, you consider serum sickness-like reaction as a diagnosis. You consult dermatology for their opinion.

The dermatologist on call confirms the diagnosis as serum sickness-like reaction.

 

Figure 1. Drug-induced urticaria in a pediatric patient (CincinattiChildren’s.org).

Serum Sickness-Like Reaction

Serum sickness was originally named due to the compilation of symptoms following injection of horse serum for treatment of scarlet fever and diphtheria1. Traditionally, the term serum sickness should be reserved for those reactions following a heterologous or chimeric protein therapeutic.

Other, similar acute inflammatory presentations are referred to as serum sickness-like reactions (SSLR), and classically present with a characteristic rash, fever, malaise, and polyarthralgia or polyarthritis one to two weeks after exposure to a causative agent2. If a patient has previously been exposed to the causative agent, the reaction may occur sooner. Serum sickness-like reaction is a type of hypersensitivity reaction following the administration of a substance, including vaccines or other medicines. Common antibiotics shown to result in SSLR are cefaclor, amoxicillin, and trimethoprim-sulfamethoxazole3-5. Serum sickness-like reaction is also highly associated with certain non-steroidal anti-inflammatory drugs, anti-cancer agents, and biologics4.  Serum sickness-like reaction can also occur following certain infections, particularly streptococcal infection, and hepatitis B6,7.

Normally self-limiting, SSLR most often subsides within weeks after discontinuing the responsible agent8. Onset of symptoms of SSLR is tri-phasic, with the first peak at day 5 post exposure, second peak at day 7 and third at day 1010. Although most seen in adults, SSRL are an increasingly common etiology of acute arthritis in children9,10.

The differential diagnosis for such reactions can include, but is not limited to:

  • Autoimmune diseases, including systemic lupus erythematosus, reactive arthritis.
  • Drug reactions, such as drug reaction with eosinophilia and systemic symptoms, Stevens-Johnson syndrome, drug-induced sweet syndrome.
  • Infectious diseases, including Epstein-Barr virus, Lyme disease, erythema multiforme, disseminated meningococcemia.
  • Vasculitis, including IgA vasculitis (Henoch-Schoenlein purpura), hypersensitivity vasculitis.

Diagnosis

The diagnosis of SSLR is typically based on the characteristic compilation of symptoms, including the typical urticarial-like lesions, arthralgias, with or without fever, secondary to, most commonly, drug exposure11. It’s important to rule out Steven-Johnson Syndrome/Toxic Epidermal Necrolysis in both pediatric and adult populations with lack of mucous membrane involvement8.

Pathophysiology

Serum sickness-like reaction is a Coombs type III/immune complex mediated hypersensitivity reaction. The formation of antigen-antibodies complexes, involving an antigen and coinciding antibody, are required for the reaction to occur. The immune complex formation of serum sickness is mediated by C3 and C5a complement proteins which recruit mast cells and neutrophils to release histamines resulting in vascular permeability (Figure 2). Normally excreted by phagocytes, they are unable to clear these complexes due to the overwhelming number of complexes formed or the under performance of the mononuclear phagocyte system. These immune complexes target certain organs in the body—why they target some and not others are not well understood. Typically, they will target joint spaces, presumed to be due to the fenestrations into the synovial fluid. Once deposited in areas of the body, these complexes will activate an inflammatory response12.

Figure 2. Type III immune complex mediated hypersensitivity mechanism of serum sickness.

 

Treatment

Serum sickness-like reactions resolve when the agent responsible is discontinued and cleared from the patient’s system. Most patients do not require additional treatment. Symptoms typically subside within two to three weeks, but in some cases may linger for up to three months. If required, arthralgias and fever can be treated with non-steroidal anti-inflammatory and analgesic medications11. For patients with severe symptoms, glucocorticoid medications can be prescribed. Intravenous immunoglobulin may be indicated for worsening or unresolving symptoms. Outcomes of serum sickness and SSLR are good, and prolongation of symptoms more than 40 days is uncommon10. Offending drug should be avoided in the future. In situations where the causative agent cannot be discontinued, treatment is highly dependent on the drug in question, and should be based on a case-by-case basis13.

Case Conclusion

While in the ED, the dermatologist on call recommended to discontinue the amoxicillin that the patient was taking for Group A Strep. Supportive measures were also recommended, as well as analgesics or NSAIDs for symptom management. The dermatologist agreed to follow up with this patient in the subsequent days to ensure resolution of symptoms and whether future treatment was needed.

References

  1. von Pirquet CF, Schick B. (Die Serumkrankheit). Serum Sickness, Schick B (Ed), Williams & Wilkins, Leipzig 1905 (translation Baltimore 1951).
  2. Vincent C, Revillard JP. Antibody response to horse gamma-globulin in recipients of renal allografts: relationship with transplant crises and transplant survival. Transplantation 1977; 24:141.
  3. Clark BM, Kotti GH, Shah AD, Conger NG. Severe serum sickness reaction to oral and intramuscular penicillin. Pharmacotherapy 2006; 26:705.
  4. Brucculeri M, Charlton M, Serur D. Serum sickness-like reaction associated with cefazolin. BMC Clin Pharmacol 2006; 6:3.
  5. Stricker BH, Tijssen JG. Serum sickness-like reactions to cefaclor. J Clin Epidemiol 1992; 45:1177.
  6. Hengge UR, Scharf RE, Kroon FP, Pfeffer K. Severe serum sickness following pneumococcal vaccination in an AIDS patient. Int J STD AIDS 2006; 17:210.
  7. Liang, Jake T. “Hepatitis B: the virus and disease.” (2009): S13-S21.
  8. Wener, Mark H., N. F. Adkinson Jr, and A. M. Feldweg. “Serum sickness and serum sickness-like reactions.” UpToDate. Wolters Kluwer Health, Philadelphia, PA (2013).
  9. Yorulmaz A, Akın F, Sert A, et al. Demographic and clinical characteristics of patients with serum sickness-like reaction. Clin Rheumatol 2018; 37:1389.
  10. Kunnamo I, Kallio P, Pelkonen P, Viander M. Serum-sickness-like disease is a common cause of acute arthritis in children. Acta Paediatr Scand 1986; 75:964.
  11. Del Pozzo-Magaña, Blanca R., and Alejandro Lazo-Langner. “Serum sickness-like reaction in children: review of the literature.” Dermatology 7 (2019): 106-111.
  12. Tolpinrud WL, Bunick CG, King BA. Serum sickness-like reaction: histopathology and case report. J Am Acad Dermatol 2011; 65:e83.
  13.  Bayraktar F, Akinci B, Demirkan F, et al. Serum sickness-like reactions associated with type III insulin allergy responding to plasmapheresis. Diabet Med 2009; 26:659.
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Tips and Tricks on Assessing a Pediatric Hand Injury

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Medical Student Clinical Pearl by Borum Yang

 

MD Candidate, Class of 2024

Dalhousie University

Reviewed by Dr. B Ramrattan

Copy Edited by Dr. J Vonkeman

Pdf Download: EMSJ Tips and Tricks on Assessing a Pediatric Hand Injury

 

Presentation 

You’ve just arrived for your shift in the emergency department, when your preceptor says, “How about you go see this 6-year-old in room 12?”.

As a 3rd year clerk, you pick up the chart and read: “6yr old, hand injury.”

What Will Be Your Approach to History Taking? 

A mnemonic a cool R1 taught you last week pops into your head: HAND 1

H: How

You recall that knowing the context and mechanism of injury will help guide your physical exam and generate a list of differential diagnosis2. Was it a FOOSH? Laceration with a potential tendon injury? High pressure injection injury increasing the risk of compartment syndrome?

H: Hobbies

Sports and activities are important to note in pediatric hand injuries, as it will impact management. Kids can be less compliant with non use or being protective of their injured hand. We don’t want lack of immobilization to be the cause of malunions and dehisced wounds3.

A: Altered sensation

Ask about paresthesia or numbness as it can indicate a nerve injury.

N: Needle/tetanus shot

Vaccinations up to date? Because if they were rolling in the dirt or got into a fight with the neighbour’s dog, you may need to grab that tetanus shot.

N: Non-accidental injury/ Child abuse

While most childhood fractures are caused by accidental trauma, it is important to always have this in the back of your head. Be on the lookout for red flags and inconsistencies in history including unwitnessed injury, or recurring fractures. Look for presence of other injuries and bruising and /or fractures at various stages of healing4.

D: Dominant hand

From the history, it seems like the kid was playing basketball, and at one point the flying ball landed directly on the kid’s outstretched fingers. They have been complaining of pain ever since.

What Will Be Your Approach to Physical Examination? 

You quickly realize that the physical exam will be a challenge, as the kid is distracted and guarding their painful hand. Inspection alone can go along way with peds exams. You quickly go through the SEADS in your head:

On inspection, there is an obvious swelling and bruising of the right small finger. You quickly glance at the rest of the hand to check for other abnormalities or deformities. Nail beds and nail folds intact? Normal creases of the hands and fingers? Any areas of laceration or open wounds?  Unusual skin changes, color changes, or atrophy of the thenar and hypothenar eminence? Don’t forget to compare findings with the non-injured hand.

Next, you test sensation of the median, ulnar and radial distribution by asking if the kid can feel touch over their thumb, small finger and back of their hand.

Now determine active and passive range of motion. If the kid is not capable of following directions, asking the kid to play ROCK PAPER SCISSORS 5 is a good way to quickly glance at the motor function and integrity of tendons. Being able to straighten out all fingers without evidence of extensor lags. Making a full fist makes you less suspicious of a flexor tendon injury. Being able to cross fingers or manipulate them makes you less suspicious of an ulnar nerve injury.

Next, you want to check for any evidence of displaced or rotated fractures by observing the cascade of the fingers. A trick is to ask the kid to totally relax the hand, and you put the wrist in passive flexion. All fingers should passively extend. Then, you put his wrist in passive extension. All fingers should passively flex and for the most part point towards the base of the thumb. This is called the tenodesis exam and is helpful in looking for tendon injuries independent of nerve or muscle function.

Lastly, you keep chatting with the child while you gently palpate the wrist, carpal bones including the snuff box, PIP, DIP, MCP joints to rule out any other injuries.

There is normal capillary refill, and focal tenderness on palpation at the base of the proximal phalanx.

You report back to your preceptor and decide to order a hand x ray.

Figure 1: PA radiograph showing minimally displaced oblique Salter Harris type II fracture of the proximal phalanx of the right small finger6.

 

Upon discussion, the right hand is immobilized in an ulnar gutter to ensure proper immobilization. The time window for intervention maybe shorter in children than adults due to faster healing times. A call to a hand surgeon at the time of presentation is never a bad idea if you are unsure of the management. The kid is discharged with a follow up with the plastic surgeon as an outpatient within a week.

Summary

 

  1. Assessing hand injuries in pediatric patients can be challenging due to ability or willingness to cooperate. It can be helped with thorough observation, and use of familiar gestures and “games”
  2. The complete hand exam includes assessment of the skin, vascularity, sensation, motor function and the underlying skeleton.
  3. Management of pediatric hand fractures differ from adult fractures due to differences in anatomy, rate of healing and patient compliance.

Conclusion 

A week later, ERCP confirms that the mass is in fact a pancreatic pseudocyst. Pancreatic pseudocysts are collections of fluid with a well-defined wall that lack the epithelium required to be classified as true cysts. Classically, they form after an episode of acute pancreatitis, but they are also seen in chronic pancreatitis, in obstruction of the pancreatic duct, and after pancreatic trauma.8 The cyst is drained endoscopically, a technique that is now considered preferable to a percutaneous approach due to its excellent rates of resolution (82-94%).9 The patient’s jaundice resolves over the following weeks and repeat laboratory investigations normalize within two months.

Helpful Videos from Boston Children’s Hospital on the Pediatric Hand Examination

References

  1.  

    1. Fox, S. (2023, May 16). Finger injuries: Basics and bones. Don’t Forget the Bubbles. https://dontforgetthebubbles.com/finger-injuries-basics-and-bones/
    2. Taghinia, A. H. (2020, May 18). 39 Pediatric Hand Trauma. Plastic Surgery Key: Fastest Plastic Surgery & Dermatology Insight Engine. Retrieved June 15, 2023, from https://plasticsurgerykey.com/39-pediatric-hand-trauma/
    3. Helman, A. (2023). Ep 178 Hand Injuries – Pitfalls in Assessment and Management. Emergency Medicine Cases. https://emergencymedicinecases.com/hand-injuries-assessment-management/
    4. Chauvin-Kimoff L, Allard-Dansereau C, Colbourne M. The medical assessment of fractures in suspected child maltreatment: Infants and young children with skeletal injury. Paediatr Child Health. 2018;23(2):156-160. doi:10.1093/pch/pxx131
    5. Marsh AG, Robertson JS, Godman A, Boyle J, Huntley JS. Introduction of a simple guideline to improve neurological assessment in paediatric patients presenting with upper limb fractures. Emerg Med J. 2016;33(4):273-277. doi:10.1136/emermed-2014-204414
    6. Wahba G, Cheung K. Pediatric hand injuries: Practical approach for primary care physicians. Can Fam Physician. 2018;64(11):803-810.

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Could it be Kawasaki Disease?

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Medical Student Pearl by Farhad Hossain

MD Candidate, Class of 2024

Dalhousie University

Reviewed by Dr. M McGraw

Copy Edited by Dr. J Vonkeman

Pdf Download: EMSJ Could it be Kawasaki Disease FHossain

 

 

 

Case Presentation

A 6-year-old female presents to the Emergency Department with a history of a fever over 5 days. She had initially visited the ED a few days ago, where croup was suspected, and she was administered a dose of dexamethasone with minimal improvement. On the day she was brought in for the second time her fever had peaked. Her mom reports increased fatigue and decreased PO intake over the duration, as well as rash.

On physical exam vitals were stable aside from an elevated temperature. Mucosal changes were observed inside her mouth and on her tongue, a non-pruritic rash was present over most of her body, and she had enlarged cervical nodes and an otitis media of the right ear. Further examination showed no pharyngitis, no conjunctivitis, lungs were clear, and heart sounds were normal.

Aside from previous croup and infections, she is otherwise healthy.

Labs yielded elevated CRP and WCC.

Given the clinical picture you consider Kawasaki Disease.

Kawasaki Disease

Kawasaki disease (KD) is an acute systemic vasculitis that mostly affects small and medium size vessels.1-3 It is typically self-limited and usually presents in those under the age of 5.1 Kawasaki disease is now the most common cause of acquired heart disease in children in developed countries due involvement of the coronary arteries.4,5 There are no pathognomonic tests, so diagnosis is dependent on key clinical signs and exclusion of other diagnoses on the differential. A differential can include the following:

  • Scarlett fever
  • Peritonsillar abscess
  • Group A Strep
  • Rheumatic fever
  • Measles

Etiology and Pathophysiology

While several theories have been proposed to explain the cause of KD, none have been definitively proven. Evidence suggests that genetic factors increase the predisposition of KD as siblings are more likely develop it than the general population, as well as those of Japanese descent.3,4 The trigger for the disease has also been believed to be some viral or bacterial antigen that enters the body through mucosal surfaces such as the lung as roughly 40% of children diagnosed with KD tested positive for a viral pathogen.1-4 Various cytokines and immune cascades lead to myocarditis and arteritis, eventually this may cause weak spot in the vessel that predisposes the formation of aneurysms.2,4

Diagnosis

The diagnosis of KD is clinical and requires the presence of fever that has persisted for 5 or more days that is not better explained by another cause and 4/5 of the following:1,3-6

  • Extremity changes such as erythema of the palms/soles and desquamation of the fingers/toes
  • An erythematous rash that is commonly a maculopapular eruption, but urticarial and multiforme-like rashes have been seen. The rash is usually diffuse and affects the trunk and extremities.
  • Bilateral bulbar conjunctival injection with uveitis often observed.
  • Changes to the oral mucosa include erythema, fissuring, strawberry tongue (erythema and prominent fungiform papillae), and diffuse erythema of the oral mucosa.
  • Cervical adenopathy is usually unilateral and confined to the anterior cervical triangle but is the least common clinical finding observed.

Patients can meet the definition of typical or classical KD, but those who do not meet the set criteria can be diagnosed with incomplete KD based off of clinical, laboratory, and echocardiographic findings.6 The following figure shows the evaluation of suspected KD:6

Figure 1: Algorithm for the evaluation of typical Kawasaki Disease. Figure obtained from UpToDate.

 

Aside from measuring CRP, additional lab findings are assessed in those with incomplete KD. The evaluation of suspected incomplete KD is shown in the below figure:1

 

Figure 2: Algorithm for the evaluation incomplete Kawasaki Disease. Figure obtained from McCrindle et al.

People with either complete or incomplete KD should receive an echocardiogram to assess for coronary artery aneurysm in the acute phase of the disease, as well as other cardiac abnormalities.1 It is common for initial echocardiography to be normal, but it does establish a baseline for sequential scans.

Treatment

Treatment for KD should be initiated immediately if clinical criteria are met. It is treated with intravenous immunoglobulin (IVIG) and high dose aspirin.1-6 The maximum dose of IVIG is 2 g/kg and it has been shown that increasing dose (up 2 kg/kg) reduces risk of CA aneurysms and duration of fever.1,5 Aspirin, usually 30 to 100 mg/day divided into 4 doses, modifies the risk in KD leading to lower risk of thrombosis.1,3,5 Studies have demonstrated that combining IVIG with corticosteroids has better effect on reducing coronary artery abnormalities in those who are refractory to initial therapy.1,4 Disease modifying anti-rheumatic drugs and antibodies have been used to treat KD, but there is not enough evidence to recommend their use as treatment.3 Patients often start seeing improvements in 36 to 48 hours. Long term management depends on the patient and the risk of coronary events reaches a peak at 5 to 6 weeks after the acute phase.

Case Conclusion

The patient was started on amoxicillin 500 mg tid down in the Emergency Department for the otitis of the right ear and within 12 hours showed improvement. It was determined she met 3 of 5 criteria for KD along with the fever that persisted for 5 days, so an echocardiogram was ordered. Upon review of the echocardiogram there were no findings suggestive of KD. The patient was discharged with a script of amoxicillin and instructed to follow up with her family doctor if conditions worsen.

References

  1. McCrindle BW, Rowley AH, Newburger JW, et al. Diagnosis, Treatment, and Long-Term Management of Kawasaki Disease: A Scientific Statement for Health Professionals From the American Heart Association. Circulation. 2017;135(17). doi:10.1161/CIR.0000000000000484
  2. Noval Rivas M, Arditi M. Kawasaki disease: pathophysiology and insights from mouse models. Nat Rev Rheumatol. 2020;16(7):391-405. doi:10.1038/s41584-020-0426-0
  3. Ramphul K, Mejias SG. Kawasaki disease: a comprehensive review. Arch Med Sci Atheroscler Dis. 2018;3(1):41-45. doi:10.5114/amsad.2018.74522
  4. Owens AM, Plewa MC. Kawasaki Disease. In: StatPearls. StatPearls Publishing; 2023. Accessed March 30, 2023. http://www.ncbi.nlm.nih.gov/books/NBK537163/
  5. Galuppo J, Kowker A, Rolfs J, Nicholas J, Schmidt E. Kawasaki disease: Shedding light on a mysterious diagnosis. J Am Acad Physician Assist. 2020;33(7):18-22. doi:10.1097/01.JAA.0000668792.41976.f2
  6. Sundel R. Kawasaki disease: Clinical features and diagnosis. Post TW, ed. UpToDate.Waltham, MA: UpToDate Inc. UpToDate.com (Accessed on March 30, 2023)

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Pediatric Hip Dislocation & Reduction

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Pediatric Hip Dislocation & Reduction

Resident Clinical Pearl (RCP) – November 2022

Dr. Nick Byers , R2 iFMEM, Dalhousie University, Saint John, New Brunswick

Reviewed/Edited by Dr. Brian Ramrattan

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:

  1. 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.

Post reduction film:

References:

https://www.merckmanuals.com/professional/injuries-poisoning/dislocations/hip-dislocations

https://www.emnote.org/emnotes/captain-morgan-hip-reduction-technique

CASTED course manual, Arun Sayal

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

https://usmlepathslides.tumblr.com/post/64398003332/posterior-hip-dislocation-posterior-hip

https://posna.org/Physician-Education/Study-Guide/Hip-Dislocations-Traumatic

https://www.ochsnerjournal.org/content/18/3/242/tab-figures-data

https://coreem.net/core/hip-dislocation/

https://westjem.com/case-report/emergency-physician-reduction-of-pediatric-hip-dislocation.html

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Vascular Access In Children: Solve the Puzzle

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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

  1. Prepare instruments: cleansing solution, tourniquet, catheter needle, connecting tube, flush, dressing, gauze, and stabilizer tape.
  2. 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.
  3. Apply tourniquet proximal to the site of insertion to enhance visualization
  4. Identify proper vein by visualization, palpation and utilizing the transilluminator or infrared light
  5. Clean the skin as per the facility protocol
  6. Hold the needle between the thumb and forefinger with the dominant hand and stretch the skin with the other hand
  7. 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.
  8. 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:

  1. 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.
  2. 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.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. 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.
  10. 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.
  11. 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.
  12. 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

 

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A Summary of Bronchiolitis

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A Summary of Bronchiolitis: A review of bronchiolitis, evidence behind various treatment regimens, and suggested admission criteria – A Resident Clinical Pearl

 Melanie Johnston, R3

Integrated FMEM, Dalhousie

Reviewed by Dr. Patricia Dutton

Copyedited by Dr. Mandy Peach

Respiratory illnesses are the second most common ED presentation for paediatric patients, particularly during the winter months, in Canada. 1,2 These paediatric patients with respiratory pathologies are at risk of rapid clinical deterioration; a thorough history and exam with careful attention to respiratory evaluation is critical. Three of the most common paediatric respiratory complaints presenting to the ED include croup, asthma, and bronchiolitis. This pearl will focus on a review of bronchiolitis, its presentation, evaluation, and the evidence behind various treatments.

What is bronchiolitis:

Bronchiolitis is a viral lower respiratory tract infection. It is characterized by obstruction of small airways cause by acute inflammation, swelling/edema, and necrosis of the cells lining the small airways.2 Airways are further narrowed by increased mucous production. The most common causes are respiratory syncytial virus (RSV), influenza, rhinovirus, adenovirus, and parainfluenza.2 These viruses are transmitted by secretions from the nose/mouth and via respiratory droplets in the air. Co-infection with multiple viruses occurs in 10-30% of hospitalized children.2

Figure 1: Pathophysiology of Bronchiolitis.3

 

Epidemiology:
RSV season generally begins in November and persists until April. Bronchiolitis generally presents with a first episode of wheezing before the age of 24 months during the winter months.2 It is the most common reason for admission to hospital in the first year of life in Canada, and more than one-third of children will be affected by bronchiolitis in their first two years of life.2

Presentation:

Bronchiolitis may present with a wide range of symptoms from mild upper respiratory tract infection symptoms (cough, rhinorrhea, fever) to respiratory distress (tachypnea, wheeze, grunting, indrawing, abdominal breathing, and retractions).4 The peak severity of illness usually occurs on day 2-3 of the illness with resolution over 7-10 days.2,6 Cough can persist in infants for up to three weeks after onset.

Pediatric populations at risk for more serious illness include:
– Age <3 months
– Infants born prematurely (<35 weeks gestation)
– Chronic lung disease
– Congenital heart disease
– Chronic neurological conditions
– Immunodeficiency
– Trisomy 21

Patients with the above risk factors are at risk of rapid clinical deterioration even if presenting early in illness with mild symptoms.2,5

Diagnosis:


The diagnosis of bronchiolitis is considered to be clinical based on history and physical exam. The illness generally begins with a 2-3 day prodrome of mild URTI symptoms including cough, fever, rhinorrhea. This may progress to tachypnea, wheeze, and signs of respiratory distress.2 If respiratory distress is interfering with feeding, there may be signs of dehydration (delayed cap refill, dry mucous membranes, no tears produced with crying). Initial assessment should focus on overall appearance, breathing, and circulation. A tool to assist in establishing a general first impression of the paediatric patients stability is the paediatric assessment triangle. Abnormalities in any domain of the triangle (appearance, work of breathing, circulation) should be noted and factored into initial workup with potential to decompensate, with abnormalities in two domains indicative of potentially serious illness.

Figure 3: Pediatric Assessment Triangle.1

Signs of respiratory distress to note on exam include:

– Tachypnea
– Intercostal/subcostal retractions
– Accessory muscle use
– Nasal flaring
– Grunting
– Colour change or apnea
– Wheezing
– Low O2 saturation (<90%)

In stratifying the severity of illness in bronchiolitis, the Royal Children’s Hospital of Melbourne has proposed the following chart to assist with assessment:

Figure 4: Stratifying severity of illness in bronchiolitis, adapted from RCHM.5

Investigations

Bronchiolitis is considered to be a clinical diagnosis. As such, the majority of patients won’t require any additional investigations. If there is diagnostic uncertainty, then the following investigations may be considered:

Management:

Bronchiolitis is a self-limiting disease with peak severity generally at day 3-4 of illness.2,5,6 Most children have mild disease and can be managed with supportive care at home. For those ultimately admitted, focus in hospital is on supportive care with assisted feeding, nasal suctioning, and oxygen therapy as needed.

Disposition:

Most children do well and the symptoms will peak by day 3-5 of illness.

Criteria for safe discharge home include:
– O2 > 90-92%
– Adequate oral hydration
– Mild respiratory symptoms
– Access to reliable follow-up care if needed.2

Criteria for hospital admission include:

– Persistent oxygen saturation <92% and requiring supplemental oxygen AND/OR
– Unable to maintain oral hydration (fluid intake 50% of normal), requiring IV or NG fluids AND/OR
– Persistent moderate-severe respiratory distress
– Apnea (observed or reported)
– Children with risk factors for severe disease (see above).2

Admission or a period of observation in the ED can be used to document feeds and monitor vital signs/oxygen status. Other considerations for admission to hospital include social circumstances, comfort of caretaker in managing child at home, distance to healthcare facility in case of deterioration, and the phase of illness.

Resources:

1. Pediatric Respiratory Illnesses, Dr Allan Shefrin. Jan 30, 2020. Accessed at https://criticallevels.ca/2020/01/30/episode-3-paediatric-respiratory-illnesses-dr-allan-shefrin/

  1. Bronchiolitis: Recommendations for diagnosis, monitoring and management of children one to 24 months of age. Canadian Pediatric Society. Friendman, J., Rieder, M., Walton, J. et al. Nov 3, 2014. Accessed at https://emergencymedicinecases.com/wp-content/uploads/filebase/pdf/CPS-guidelines-bronchiolitis.pdf.3. Bronchiolitis. Cleveland Clinic. Accessed online at: https://my.clevelandclinic.org/health/diseases/8272-bronchiolitis
  2. Bronchiolitis, Bottom Line Recommendations. Trekk: Translating Emergency Knowledge for Kids. October 2020. Accessed online at: https://trekk.ca/system/assets/assets/attachments/502/original/2021-01-08-Bronchiolitis_v_3.0.pdf?16106625135. Bronchiolitis, Clinical Practice Guidelines. The Royal Children’s Hospital Melbourne. Accessed online at: https://www.rch.org.au/clinicalguide/guideline_index/Bronchiolitis/

    6. Bronchiolitis, Episode 59. Emergency Medicine Cases. Accessed online at https://emergencymedicinecases.com/episode-59-bronchiolitis/

    7. Bronchiolitis in children: diagnosis and management. NICE guideline. June 1, 2015. Accessed online at: https://www.nice.org.uk/guidance/ng9/resources/bronchiolitis-in-children-diagnosis-and-management-pdf-51048523717

    8. https://www.connectedcare.sickkids.ca/quick-hits/2019/8/29/volume6-efnk4-nyn48-max8h-rczlx (Pediatric assessment triangle)

    9. Bronchioitis, accessed online at: https://en.wikipedia.org/wiki/Bronchiolitis.

 

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A Seal Barking… In the ED?? – Croup Management in the Emergency Department

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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:

  1. 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
  2. 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/
  3. 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
  4. 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/
  5. 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/
  6. 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/
  1. Johnson DW. Croup. BMJ Clin Evid. 2014. https://pubmed.ncbi.nlm.nih.gov/25263284/
  2. Bjornson CL, Johnson DW. Croup in children. CMAJ. 2013;185(15):1317-23. https://www.cmaj.ca/content/185/15/1317
  3. Takata, Fujikawa, Goto. Thumb sign: acute epiglottitis. BMJ Case Rep. 2016. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4904439/
  4. 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/
  5. Toward Optimized Practice. Diagnosis and Management of Croup. Clinical Practice Guideline, January 2008. www.topalbertadoctors.org/download/252/croup_guideline.pdf.
  6. 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

 

 

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Murmurs for the Learners: An approach to pediatric heart murmurs

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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:

  1. 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
  2. Heart Murmur | NHLBI, NIH. Accessed November 18, 2021. https://www.nhlbi.nih.gov/health-topics/heart-murmur
  3. Heart murmurs: MedlinePlus Medical Encyclopedia. Accessed November 18, 2021. https://medlineplus.gov/ency/article/003266.htm
  4. 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
  5. Frank JE, Jacobe KM. Evaluation and Management of Heart Murmurs in Children. Am Fam Physician. 2011;84(7):793-800.
  6. 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
  7. Physical Examination – Textbook of Cardiology. Accessed November 18, 2021. https://www.textbookofcardiology.org/wiki/Physical_Examination
  8. Pediatric Heart Murmur Recognition Program intro. Teaching Heart Auscultation to Health Professionals. Accessed November 19, 2021. https://teachingheartauscultation.com/pediatric-murmur-recognition-program-intro
  9. 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
  10. Begic E, Begic Z. Accidental Heart Murmurs. Med Arch. 2017;71(4):284-287. doi:10.5455/medarh.2017.71.284-287
  11. McConnell ME, Adkins SB, Hannon DW. Heart murmurs in pediatric patients: When do you refer? Am Fam Physician. 1999;60(2):558-565.

 

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Paediatric Supracondylar Fractures

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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

  1. https://radiopaedia.org/articles/supracondylar-humeral-fracture-2
  2. https://radiopaedia.org/articles/gartland-classification-of-supracondylar-humeral-fractures
  3. https://radiopaedia.org/articles/anterior-humeral-line
  4. https://radiopaedia.org/articles/elbow-ossification-mnemonic
  5. https://radiopaedia.org/articles/sail-sign-elbow-1
  6. https://www.orthobullets.com/pediatrics/4007/supracondylar-fracture–pediatric

 

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