Pediatric emergency medicine update - 2014

Thanks to the Marry Bridge Pediatric Emergency Department for hosting the 2014 Pediatric EM Conference. Here are a few pearls for those who were not able to make it. 
MBED 253-403-1418
One Call 253-792-6767 / 855-647-1010

ORTHOPEDICS

• Salter Harris fractures type 1 really don't need follow-up radiographs, treat for comfort. Complication rates are low and diagnosis of this is really not important. 
• Similarly, there may be little to no benefit for casting / splinting buckle fractures. Short arm splint for a few weeks may be helpful for comfort only. 
• Displacement is more tolerable in the plane of motion, especially with younger ages. 
• Consider plaster splints for kids <1 year. This may be more moldable and have fewer sharper edges than pre-formed fiberglass splints. 

ASTHMA AND BRONCHIOLITIS 

• MDI just as effective as a nebulizer... if you use a spacer (the other 1/2 of the MDI) - 2013 Cochrane Database
• 4-6 puffs on MDI = 2.5 mg neb, 8-12 puffs on MDI = 5 mg neb (1:4-6)
• Xopenex is NOT more effective than racemic albuterol, but is more expensive. There is similar efficacy, similar ED length of stay, and similar side effect profile. 
• Early administration of oral corticosteroids (within 1 hour) will improve asthma outcomes. dexamethasone as single IM dose, or 2 days orally, 0.6 mg/kg, is comparable to standard 5 days of prednisone (Keeney Pediatrics 2014). In ED can give the injectable liquid orally, and Rx for pills that can be crushed and given with chocolate syrup. 
• During the appropriate season, diffuse bilateral wheezing = bronchiolitis, don't need a chest x-ray or viral testing
• Serious bacterial illness in children 2-3 months concurrent with bronchiolitis is pretty rare, however, UTI concurrence is about 3.3% - so if anything, check a urine. 
• If improvement with albuterol in bronchiolitis in the ED, ok to send home with, but most will not have improvement with albuterol. If it doesn't help in the ED, likely no benefit at home. 
• Hypertonic salie may help but questionable data. Will not reduce ED length of stay or bounce backs 
• So what does work for bronchiolitis? fever treatment, suction nose, and oral fluids. good return precautions and follow up. 
• MBED Bronchiolitis Pathway

DIABETES AND DKA

• MBED DKA Pathway
• Check a glucose in your sick kids, 25% of DM type I present in DKA, with 15,000 new DM diagnosis each year!
• Common precipitants of DKA: stress, infection, inappropriate or missed dosing of insulin, initial presentation of type I DM
• Initial fluid bolus 10-20 ml/kg NS over first you, no more than 40 ml/kg in first 4 hours
• Continuous regular insulin at 0.1 U/kg/hr WITHOUT BOLUS (increases risk of cerebral edema)
• Goal decrease in glucose 50-100 mg/dL/hr, when glucose is <250 add glucose to fluids
• If K+ level is normal or low and urinating patient, include 20-40 mEq in maintenance fluids
• ICU criteria: impaired circulation, age <5, bicarb <15
• Consider cerebral edema with abnormal pain, neurologic abnormality, altered mental status, low HR, incontinence, headache, lethargy, intractable vomiting
• If cerebral edema, slow fluid rate to 75% maintenance, mannitol, elevated head of bed, consider 5 mL/kg of 3% hypertonic saline, airway protection with high minute ventilation 

CONSTIPATION

• Severe constipation may present with frequency small stools or diarrhea around stool balls
• Stool avoidance behaviors often precipitated by passage of painful, large stools
• Delayed passage of muconium (> 24 hours) may be an indicator of Hirschsprung's disease
• Multiple radiograph grading systems available, possible Leech et al. most reproducible - if you want to do this... google it. No clear indication for  imaging in constipation. 
• Soiling or encopresis, consider disimpaction
• Don't forget behavioral modifications and toiling education for kids
• Oral fluids, dietary fiber, laxatives (PEG 1 g/kg/day for 3-6 days) with Rx weaning 
• Maintenance dose of PEG is 0.4 g/kg/day
• PEG may be superior to lactulose for re-impaction (0 vs 23% at 3 mo)

CIRCUMCISION COMPLICATIONS

• Bleeding most commonly at the frenulum, Control with soak in gauze with epinephrine 1:1,000 to promote clotting, direct pressure, consider Dermabond (R), consider QuickClot [bbc comment], last resort... sutures 
• Other common complications: retained or migrated Plastibel, urinary retention, infection, excessive skin removal, amputation. 

SUBSTANCE ABUSE & TOXICOLOGY 

• "Butt chugging" becoming more popular - rectally absorbed alcohol to avoid taste, calories, etc. also inhaled vaporized, soaked gummy candies, soaked tampons more common. 
• 2012 most common high school intoxicants marijuana and synthetic derivatives
• New methods of marijuana use: Chapstick, gummy candy, lollipops, baked goods, crackers
• Often home made, variable amounts of THC, last longer than smoking, more likely to cause anxiety, agitation and paranoia 
• "Wax" is a new method, also called "dabbing" with 50-80% THC concentration refined marijuana 
• Mixed marijuana products hitting market - often with PCP, cocaine, amphetamines, (aka rocket fuel) to create distinct and marketable high
• Synthetic marijuana (aka spice K2, skunk, fire) more common in younger teenagers 
• Oral Rx opiate abuse more common, ? leading to heroin abuse, much more prevalent over past decade
• Acetyl Fentanyl - "not for human consumption" and currently not a controlled substance, may require more naloxone as it is 5-15x more potent than heroin, will show up as opioid on fox screen
• Codeine, promethazine and soda / alcohol (aka Purple Drank, Sizzurp, Lean, Syrup) 
• look for patches, naloxone therapy, hydration, airway protection, check tylenol levels and hepatotoxicity 
• Stimulants (aka Vit A, Godin's Potion, D-ral, Adderall) common in high school and college students for performance enhancing, very accessible due to heavy Rx in community
• "Molly", ecstasy, MDMA still common
• Bath Salts, amphetamine like, still available but legislation pending. Derived from the Khat plant (aka Ivory Wave, etc), treat with benzodiazepines and fluids, BP management 
• Cocaine, now on top 5 fastest growing in last decade, all Sx treatment with benzodiazepines 

EPI-PENS

• Most anaphylaxis is monophasic, however, 1/3 will have a biphasic reaction from 1-8 hours, mostly occurring 4-6 hours later
• IM faster and more reliable onset than SC
• OK to give through clothing
• OK to use CLEAR appearing medication in an expired Epi-Pen
• Auvi-Q, has IM epinephrine with talking instruction on device 

FEVER

• Consider UTI in girls <2 and boys <1
• Occult pneumonia has very poor IOR on chest x-ray, mostly viral lower airway disease anyway
• CBC has very poor predictability in healthy, well appearing, immunized and immunocompetent children (Bonsu Ped Inf Dis Journ 2005)
• Due to PCV vaccine, no more need for empiric CBC and blood cultures in febrile healthy kids >3mo
• If 2 doses of PCV given, no need for blood cultures in otherwise well febrile children
• If non-innunized or behind on immunizations, consider CBC and blood cultures
• Neonates and young infants ( <3mo) should get CBC, blood cultures, UA, +/- chest x-ray, consider CSF, empiric ampicillin + cefotaxime (consider acyclovir) 
• Check RSV if season appropriate, if > 2 weeks and RSV + with symptoms, normal CBC and UA, may be able to forgo LP and empiric antibiotics 
• Sickle cell patients should have empiric CBC, blood cultures, chest x-ray and empiric ceftriaxone 50 mg/kg EVEN if they have a known source of infection. Consider hematology consultation. 

ABDOMINAL PAIN

APPARENT LIFE THREATENING EVENT (ALTE)

• Apnea, color change, decreased muscle tone, gagging or choking. 
• Not a diagnosis, no association with SIDS
• Sick kids get a complete workup, including CT head
• Low risk overall for SBI
• All kids should be admitted for observation
• CPR given = ICU admission 

GI

• Bilious emesis in babies is generally a surgical emergency
• during a pyloric ultrasound, evaluation of the position of the SMA / SMV can have a 96% NPV for malrotation of the intestines 
• Ultrasound generally has a 99% NPV for intussusception 

MISC.

• EV-D68 is a DNA send out test, not CDC reportable, and treated the same as asthma and a URI, consider BiPAP. It has hit Washington State.