Most children who come into the Emergency Department present with pain or experience pain during their ED stay.1,2,3 Pain and distress during a procedure can leave a lasting impact on a child and contribute to mistrust of the medical system and compliance with future procedures.1 ,4,5 Children who use active forms of coping report less pain and distress during a procedure.3 To help with coping, when feasible, involve parents or family, nursing and a child life specialist. If the parents are willing, try to get them involved in all parts of the medical procedure.2,3 This includes positioning the patient with a parent in a secure parental-hugging hold or maintaining close physical contact throughout the procedure.6 This can easily replace immobilization of a child or the use of restraints which can cause increased fear and escalate the degree of anxiety in a child.2
During your shifts in the pediatric ED, you may encounter a few patients with adrenal insufficiency or adrenal crisis. Some of the most common causes include those patients with Addison disease, pituitary hypothalamic pathology, and those patients on chronic steroids. When these patients get sick or sustain trauma, it is important to consider giving them a stress dose of hydrocortisone. Patients in adrenal insufficiency or crisis can present with dehydration, weakness, nausea, vomiting, confusion, lethargy, and severe hypotension refractory to vasopressors. 1–3
Children with chest pain commonly present to the emergency department. Both the child and family members may think their symptoms are due to a serious illness. Among adolescents seen for their chest pain, more than 50% thought they were having a heart attack or that they had cancer.1 In reality, only 6% of pediatric chest pain has a cardiac etiology.2 Nonetheless, extensive and costly emergency department (ED) evaluations are common and there is wide practice variation.3
But prior to reassuring your patient, what can you do to reassure yourself that your patient doesn’t need a more extensive workup? What would make you suspicious for cardiac causes of pediatric chest pain?