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SAEM Clinical Images Series: Pediatric Genitourinary Bleeding

A 4-year-old female with no significant past medical history is brought to the Emergency Department by her grandmother for concern for two days of progressive vaginal bleeding. The grandmother first noted blood in the patient’s underwear the previous morning when she was helping the patient wipe and she noticed it again prior to arrival, this time saturating the patient’s underwear. There is no history of any recent falls or trauma, abdominal pain, pain to the vagina, dysuria, prior incidents of vaginal bleeding, or any noticeable behavioral changes per the grandmother. The patient lives at home with her mother but has been at her grandmother’s house for the past four days (the household consists of female cousins, grandmother, and grandfather). Of note, the patient’s father took her to a trampoline park with her younger sister two days ago.

Vitals: BP 95/68; HR 96; RR 24; 98% on room air; Temp 36.2°C; Wt 18.2 kg

General: Well-appearing 4-year-old female acting appropriately with grandmother and mother at the bedside.

Abdomen: Soft, nontender, nondistended.

Genitourinary: Normal appearing external genitalia without any skin tears/lacerations. Vaginal exam: Slow oozing bleed noted with round “doughnut” shaped tissue protruding at the vaginal opening.

Hemoglobin: 12.2 g/dL

Urinalysis (clean catch): Blood: Large; >200 RBCs, Ketones: 20, Nitrite: Negative, Leukocytes: Moderate, 19 WBCs

FSH/LH/Testosterone: Within normal limits

Urethral prolapse is a rare condition occurring in prepubertal female pediatric patients. It often presents to the emergency department with complaints of vaginal bleeding, difficulty urinating, or dysuria. The most common predisposing factors to this condition include obesity, cough, trauma, constipation, or a history of any activity that causes a sudden recurrent increase in pelvic pressure, such as a trip to the trampoline park as was the case in this patient [1]. On physical examination, urethral prolapse appears as an annular-like mucosal mass with a central dimple located between the labia majora on examination [1]. Initial treatment is medical management with topical estrogen cream in conjunction with Sitz baths and outpatient follow-up with pediatric urology or gynecology. However, persistence of the prolapse or necrosis of the distal urethra often warrants emergent pediatric urology consultation [2,3]. Recurrent cases or cases refractory to medical management will often require surgery. The patient in this case was treated with a 4-week estrogen cream taper. The patient followed up with pediatric gynecology without further complication or need for further intervention.

Child Abuse, Vaginal Trauma, Malignancies (ie: sarcoma botryoides), Infection, Vaginal foreign body, Urethral Prolapse, Precocious puberty, Hypothyroidism, and Exogenous hormone

Take-Home Points

  • Consider urethral prolapse in any prepubertal female who presents to the Emergency Department with a triage complaint of vaginal bleeding.
  • Treatment for urethral prolapse is typically conservative with topical estrogen cream and prompt follow up with pediatric urology or gynecology.
  • Always keep a broad differential for prepubertal pediatric patients with genitourinary and vaginal bleeding complaints

  • HHillyer S, Mooppan U, Kim H, Gulmi F. Diagnosis and treatment of urethral prolapse in children: experience with 34 cases. Urology. 2009 May;73(5):1008-11. doi: 10.1016/j.urology.2008.10.063. Epub 2009 Mar 13. PMID: 19285715.
  • Laufer M, Emans S. Overview of vulvovaginal conditions in the prepubertal child. Uptodate.com. https://www.uptodate.com/contents/overview-of-vulvovaginal-conditions-in-the-prepubertal-child. Published 2021. Accessed January 5, 2022.
  • Teach S. Evaluation of vulvovaginal bleeding in children and adolescents. Uptodate.com. https://www.uptodate.com/contents/evaluation-of-vulvovaginal-bleeding-in-children-and-adolescents#H11716993. Published 2021. Accessed January 5, 2022.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2023-11-12T14:19:13-08:00Nov 17, 2023|Ob/Gyn, Pediatrics, SAEM Clinical Images|
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SAEM Clinical Images Series: Unusual Scalp Lesions

scalp

A 6-year-old male presented to the pediatric emergency department (PED) for scalp lesions. He was seen by his pediatrician 2 weeks prior and prescribed antibiotics and a delousing shampoo for suspected cellulitis versus lice infestation. Symptoms did not improve despite completion of treatment. An outpatient ultrasound was performed showing “multiple scalp echogenic nodular lesions measuring from 0.5 cm to 1.2 cm in the long axis diameter.” The following differential diagnosis was entertained: lymphadenitis, benign avascular mass, epidermal inclusion cyst, or pilomatricoma, and the patient was started on clindamycin. Due to concern for an oncologic process, a surgery consultation was placed to arrange for a biopsy. Four days after the ultrasound and before the biopsy could be performed, the patient and his mother presented to the PED due to worsening symptoms. Multiple new lesions developed across the patient’s scalp which bled when pressure was applied. The patient denied fever and reported intermittent pruritus and pain over the lesion sites. The mother reported a history of travel to Ecuador one month prior to symptom onset.

Vitals: BP 98/61; Pulse 73; Temp 36.3°C (97.3°F) temporal; Resp 18; SpO2 99%, RA

Skin: Large, 3 x 3cm indurated, erythematous lesion located over the patient’s right temporal scalp (Image 1). Five additional lesions noted across the entirety of the scalp. No lesions identified below the neck. Lesions are mildly tender to palpation; no fluid able to be expressed. A small centrally located pore is noted on each lesion with appearance of pulsatile fluid level. No associated lymphadenopathy. A point-of-care ultrasound (POCUS) using a high-frequency, linear transducer was performed during the PED visit (Image 2).

Non-contributory

In short axis, there is an echogenic lesion with surrounding fluid (halo sign) suggesting a foreign body that also exhibits posterior acoustic shadowing. With the transducer held still, independent movement is visualized within the center of the lesion (Image 3).

Cutaneous furuncular myiasis due to Dermatobia hominis (botfly infestation).

Take-Home Points

  • Native to Central and South America, botfly infestation is facilitated through an infected female mosquito which deposits its eggs on the skin of a mammal on which it feeds.
  • Cutaneous furuncular myiasis is important to consider for unexplained head, neck, and extremity lesions when there is suspected travel to endemic areas and is unlikely to be recognized in the continental United States due to low prevalence.
  • Consider pertinent physical exam findings and utility of POCUS in confirming the diagnosis.

  • Harris AT, Bhatti I, Bajaj Y, Smelt GJ. An unusual cause of pre-auricular swelling. J Laryngol Otol. 2010 Mar;124(3):339-40. doi: 10.1017/S002221510999082X. Epub 2009 Aug 11. PMID: 19664319.
  • Minakova E, Doniger SJ. Botfly larva masquerading as periorbital cellulitis: identification by point-of-care ultrasonography. Pediatr Emerg Care. 2014 Jun;30(6):437-9. doi: 10.1097/PEC.0000000000000156. PMID: 24892687.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2023-09-27T08:23:43-07:00Oct 2, 2023|Dermatology, Pediatrics, PEM POCUS, SAEM Clinical Images|
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PEM POCUS Series: Pediatric Lung Ultrasound

PEM POCUS fascia iliaca block

Read this tutorial on the use of point of care ultrasonography (POCUS) for pediatric lung ultrasound. Then test your skills on the ALiEMU course page to receive your PEM POCUS badge worth 2 hours of ALiEMU course credit.

Module Goals

  1. List indications for performing a pediatric lung point-of-care ultrasound (POCUS).
  2. Describe the technique for performing lung POCUS.
  3. Recognize anatomical landmarks and artifacts related to lung POCUS.
  4. Interpret signs of a consolidation, interstitial fluid, effusion, and pneumothorax on POCUS.
  5. Describe the limitations of lung POCUS.

Child with Cough and Fever: Case Introduction

A 6-year-old boy presents to the emergency department complaining of cough for 3 days and fever for the last day. His fever was 103°F this morning and he received ibuprofen. He has also had abdominal and back pain. He was seen at the emergency department earlier in the day where he had a chest X-ray 6 hours prior that was interpreted as negative for consolidation and bloodwork including a complete blood count and comprehensive metabolic panel that were within normal limits. He presents with persistent cough and fever and now has increased work of breathing.

On arrival, his vital signs are:

Vital SignFinding
Temperature99.7 F
Heart Rate138 bpm
Blood Pressure102/61
Respiratory Rate32
Oxygen Saturation (room air)100%

He is well appearing but has increased work of breathing. His lungs have decreased breath sounds and crackles over the left lung base. No wheezes are appreciated. He has mild subcostal retractions. His abdomen is soft, non-tender, and non-distended. His back is non-tender to palpation. He has normal HEENT, neck, and cardiac examinations, with the exception of tachycardia as above.

Given his presenting signs and symptoms in the setting of a recent chest X-ray that was interpreted as normal, you decide to perform a lung point-of-care ultrasound (POCUS) examination.

Lung POCUS can be performed for a wide range of cardiorespiratory complaints including cough, fever, difficulty breathing, chest pain, hypoxia, and chest trauma. It can also facilitate early diagnosis, allowing for appropriate management. Children are excellent candidates for lung POCUS as they have thinner chest walls and smaller thoracic widths than adults.

Background

The lungs were traditionally considered poorly accessible to ultrasound, as ultrasound waves cannot penetrate air-filled structures; however, lung POCUS relies on the interpretation of patterns of artifacts to evaluate the normal, air-filled lungs.

When there is lung pathology, the consolidation or fluid allows for direct visualization of the pathology with lung POCUS and replaces the air artifacts. Fluid in a consolidation or effusion is easily visualized with ultrasound if the fluid has direct contact with the pleural surface. As lung POCUS will only visualize the lung under the probe, it is essential to completely evaluate the lungs anteriorly, laterally, and posteriorly to avoid missing pathology.

Technique

Positioning and Probe

lung POCUS comfortable positioning child

Figure 1: Younger children can sit in their parent’s lap and give a hug for lateral and posterior lung scanning.

  • The patient should be in a position of comfort: supine, sitting, or in parent’s lap (Figure 1).
    • Warm gel helps with the child’s comfort.
    • Distractions such as a toy, book, or phone/tablet can also help ease anxiety.
  • Use a linear high frequency probe. If increased depth is needed, such as in the evaluation for effusion, a curvilinear or phased array probe may also be used.

 

Scanning Protocols

There are different protocols to scan the lung depending on the purpose of the evaluation. For example, in pneumothorax, we focus on the anterior chest where air rises in a supine patient, and for the extended Focused Assessment with Sonography (eFAST) exam, we focus on more dependent areas where pleural fluid or blood collects. Below we discuss the complete lung exam which is often used in evaluating for pneumonia.

Lung POCUS anatomy 6-zone scan area

Figure 2: The 6-zone lung scanning protocol includes anterior, lateral, and posterior lung fields bilaterally.

  • A 6-zone lung ultrasound protocol is used for a complete lung examination (Figure 2):
    • Anterior lungs bilaterally are scanned in the mid-clavicular line from the apex to the base of the lungs and diaphragm.
    • Lateral lungs bilaterally are scanned in the mid-axillary line from the apex to the base of the lungs and diaphragm.
    • Posterior lungs bilaterally are scanned medial to the scapulae and lateral to the vertebral bodies from the apex to the base of the lungs and diaphragm.
  • Place the probe longitudinally, perpendicular to the ribs, with the probe marker towards the patient’s head. Identify anatomical landmarks on ultrasound (Figure 3, Video 1).
Lung POCUS A lines normal child

Figure 3: Normal lung with A-lines in longitudinal (left) and transverse (right) orientations

 

Video 1: Normal lung POCUS in longitudinal orientation

 

Video 2: Normal lung POCUS in transverse orientation

Normal Lung Findings

  1. Ribs: Hyperechoic, curvilinear structure with posterior acoustic shadowing
  2. Pleural line: Hyperechoic line immediately deep to the ribs
    • Lung sliding sign: Visceral and parietal pleural are juxtaposed and sliding against each other with respirations, giving the pleural line a shimmering or “ants marching on a log” appearance. For additional examples, see the PEM POCUS Endotracheal Intubation Confirmation article, specifically in Section 2 – Indirect Confirmation: Visualize Bilateral Lung Sliding.
  3. Lungs filled with air: Visualized on POCUS as horizontal A-lines, which are a reverberation artifact of the pleural line. The pleural line is reflected as the ultrasound beams bounce back and forth between the probe and the highly reflective pleural line, and therefore the distance between A-lines is the same as the distance between the probe and the pleural line (Figure 4).
Lung POCUS A lines reverberation normal

Figure 4: Reverberation artifact and A-lines. The probe sends out ultrasound waves that bounce back and forth between the highly reflective pleural line and the probe (leftmost 3 arrows). The ultrasound machine then interprets these signals as A-lines equidistant from the pleural line (rightmost 3 arrows).

Lung POCUS pulmonary consolidation

Figure 5: Pneumonia with sonographic hepatization, air bronchograms, and irregular pleural line

 

Video 3: Lung POCUS showing a pneumonia

 

Consolidation will appear as a subpleural, hypoechoic, irregularly shaped area, which will move with respirations. It can have the following findings on lung POCUS:

  • Hepatization refers to the homogenous, soft tissue echotexture due to fluid in the lung.
  • Shred sign refers to the irregular borders of the non-pleural edge of a pneumonia that is not translobar and thus adjacent to normal lung.
  • Pleural line irregularities refer to the hypoechoic or fragmented pleural line at the consolidation.
  • Hyperechoic air bronchograms are air in the bronchioles (white dots or branches) surrounded by hypoechoic (dark), fluid-filled lung (Figure 5 and Video 3).

Lung POCUS B lines waterfall

Figure 6: Lung POCUS showing B-lines (A) and a confluence of B-lines, known as the waterfall sign (B)

Video 4: Lung POCUS showing a confluence of B-lines (waterfall sign)

B-lines represent interstitial fluid and may arise from viral infection, pulmonary edema, or acute respiratory distress syndrome (ARDS).

  • POCUS appearance:
    • Ring-down artifacts that arise from the pleural line and extend to the bottom of the screen (Figure 6A). They move with lung sliding and erase A-lines at their intersection.
    • More than 3 B-lines in an intercostal space has been considered abnormal in the adult population. However it may not always be feasible to accurately count the number of B-lines.
    • The distribution of B-lines may help differentiate etiologies, with focal B-lines in pneumonia or atelectasis, and diffuse B-lines in pulmonary edema or ARDS.
  • Waterfall sign: A confluence of B-lines (Figure 6B and Video 4)

POCUS lung subpleural consolidation

Figure 7: Lung POCUS with subpleural consolidation

Video 5: Lung POCUS with subpleural consolidation

Subpleural consolidations are small hypoechoic or tissue-like structures with pleural line abnormalities and blurred margins (Figure 7 and Video 5). They measure <1 cm and are usually seen with a viral process.

Lung POCUS pleural effusion

Figure 8: Pleural effusion with linear probe (A) and phased array probe for increased depth (B).

Video 6: Lung POCUS with pleural effusion using linear probe

A pleural effusion is visualized as anechoic (black) fluid between the chest wall and lung or between the diaphragm and lung (Figure 8 and Video 6).

  • Scan the lateral chest in the posterior axillary line in the supine patient, as fluid is dependent and will accumulate posteriorly.
  • The pleural effusion can be fluid in an infectious process or blood in the setting of trauma.

Absent Lung Sliding

Video 7: Lung POCUS showing a pneumothorax with absent lung sliding

In pneumothorax, there is air between the visceral and parietal pleural, so there will be no lung sliding visualized on lung POCUS.

  • Scan for a pneumothorax in the anterior chest in the 2nd-4th intercostal space in the mid-clavicular line in a supine patient, as air will rise to the highest point in the chest.
  • The pleural line will appear as a static, hyperechoic line (Video 7).
  • There will be A-lines visualized, but no B-lines.
    • Pro Tip: The presence of B-lines is highly sensitive against the presence of a pneumothorax in that location.

 

Lung Point

Video 8: Lung POCUS with evidence of a lung point

Lung point, when seen, is the edge of the pneumothorax, where regular lung sliding occurs adjacent to absent lung sliding (Video 8).

  • Lung point is 100% specific for pneumothorax, but it may not be visualize d for a large pneumothorax with lung collapse.

 

Motion (M) Mode

Figure 9: Lung POCUS showing a normal lung with the seashore sign (A) and a pneumothorax with the barcode sign (B)

M-mode may also be used to evaluate for pneumothorax.

  • Normal lung: There will be the seashore sign, with a granular pattern representing aerated, moving lung below the pleural line (Figure 9a).
  • Pneumothorax: There will be a barcode or stratosphere sign, with no aeration or movement below the pleural line (Figure 9b).

Additional examples can be found in the PEM POCUS: Endotracheal Tube Confirmation article in Section 2 – Indirect Confirmation: Visualize Bilateral Lung Sliding.

lung abscess

Figure 10: Lung abscess with adjacent lung consolidation and pleural effusion

 

Lung abscess may also be evaluated by lung POCUS and will have a hypoechoic fluid collection (Figure 10).

  • Consolidated lung and pleural effusion are also commonly seen.
  • Lung ultrasound is more accurate than chest X-ray at evaluating lung abscess.

Lung pathology may be missed without a complete lung POCUS scanning protocol, as you will only see pathology located directly under the probe. The lung POCUS is also operator-dependent, and it has a steep learning curve.

False Negative:

  • POCUS can’t visualize a centrally located pneumonia not extending to the pleural surface. A lung consolidation needs to extend to the pleural surface to be visualized on lung POCUS.
  • However, a study in adult patients showed that 99% of lung consolidations extend to the pleura [1]. Thus, in children with smaller lung mass, most consolidations likely will be detected by lung POCUS.

False Positives:

Left Lower Chest

  • Caution is needed at the left lower chest, as the spleen and air in the stomach can be misinterpreted as consolidation (Figure 11).
  • Locate the diaphragm in the left lower chest to be sure you are evaluating lung above the diaphragm.
stomach spleen

Figure 11: The spleen and the stomach with air may be misinterpreted as consolidation.

Thymus

  • In younger children, the thymus may be misinterpreted as a consolidation.
  • The thymus will be adjacent to the heart, have regular echotexture, no air bronchograms, and regular borders (Figure 12).
thymus

Figure 12: Thymus (*) located adjacent to the heart

 

There have been multiple studies of lung POCUS identifying pneumonia in children, and several meta-analyses have been published [2-4]. Table 1 summarizes these studies, showing an overall high accuracy for lung POCUS diagnosis of pneumonia in children.

StudyNSensitivitySpecificityComments
Pereda et al., Pediatrics 20158 studies; 765 patients

96%

93%

Evidence supports lung POCUS as an alternative for diagnosis of pneumonia in children.
Balk et al., Pediatr Pulmonol 201812 studies; 1510 patients

96%

95%

Lung POCUS had significantly better sensitivity than chest X-ray, which had a sensitivity of 87%.
Tsou et al., Acad Emerg Med 201925 studies; 3353 patients

94%

92%

Significant difference in accuracy between novice and advanced sonographers.
Table 1. Meta-analyses of lung POCUS for diagnosis of pneumonia in children

 

1. Decreased radiation and length of stay

  • A randomized controlled trial comparing lung POCUS to chest X-ray for diagnosis of pneumonia showed a 39% reduction in chest X-ray utilization and a decreased emergency department length of stay from 180 to 132 minutes in the patients receiving only lung POCUS with no cases of missed pneumonia [5].

2. Best view for pneumonia

  • A study looking at lung consolidation locations in children with pneumonia found that 96% of pneumonias were detected by the transverse view, compared to 86% in the longitudinal view.
  • The authors concluded that the transverse orientation detects more pneumonia than the longitudinal view, and that omission of either orientation or any lung zone may miss pneumonia [6].

3. Pneumothorax: POCUS is better

  • A meta-analysis of chest X-ray vs ultrasound for diagnosis of pneumothorax showed that ultrasound had a sensitivity of 88% and specificity of 99% compared to sensitivity of 52% and specificity of 100% for chest X-ray. Furthermore, lung POCUS performed specifically by non-radiologist clinicians had a sensitivity of 89% and specificity of 99% [7].

Case Resolution

The patient’s chest X-ray from earlier in the day was interpreted by the pediatric radiologist as negative for consolidation or other pulmonary pathology. You performed a lung POCUS with a linear, high-frequency probe and observed the following:

Video 9: A lung POCUS of the case patient’s left lower lung (affected side)

Though this child with cough, fever, focal lung findings, and respiratory distress had a negative chest X-ray performed 6 hours earlier, your POCUS evaluation identified a left lower lobe pneumonia which helped you make your diagnosis and start the appropriate treatment.

ED Course

The patient received antibiotics for pneumonia. His work of breathing increased during his emergency department visit, and he was started on high flow nasal cannula at 30 L/min with improvement in his respiratory status. He was admitted to the pediatric intensive care unit. He had a repeat chest X-ray 12 hours later that was interpreted by the pediatric radiologist as having new pleural and parenchymal changes in the left hemithorax with questionable pneumonia. He continued antibiotics, and his repeat X-ray 48 hours later showed a clear left lower lobe consolidation with pleural effusion.

 

Learn More…

References

  1. Lichtenstein DA, Lascols N, Mezière G, Gepner A. Ultrasound diagnosis of alveolar consolidation in the critically ill. Intensive Care Med. 2004 Feb;30(2):276-281. PMID: 14722643
  2. Pereda MA, Chavez MA, Hooper-Miele CC, et al. Lung ultrasound for the diagnosis of pneumonia in children: a meta-analysis. Pediatrics. 2015 Apr;135(4):714-22. PMID: 25780071
  3. Balk DS, Lee C, Schafer J, et al. Lung ultrasound compared to chest X-ray for diagnosis of pediatric pneumonia: A meta-analysis. Pediatr Pulmonol. 2018 Aug;53(8):1130-1139. PMID: 29696826
  4. Tsou PY, Chen KP, Wang YH, et al. Diagnostic Accuracy of Lung Ultrasound Performed by Novice Versus Advanced Sonographers for Pneumonia in Children: A Systematic Review and Meta-analysis. Acad Emerg Med. 2019 Sep;26(9):1074-1088. PMID: 31211896
  5. Jones BP, Tay ET, Elikashvili I, et al. Feasibility and Safety of Substituting Lung Ultrasonography for Chest Radiography When Diagnosing Pneumonia in Children: A Randomized Controlled Trial. Chest. 2016 Jul;150(1):131-8. PMID: 26923626
  6. Milliner BHA, Tsung JW. Lung Consolidation Locations for Optimal Lung Ultrasound Scanning in Diagnosing Pediatric Pneumonia. J Ultrasound Med. 2017 Nov;36(11):2325-2328. PMID: 28586113
  7. Ding W, Shen Y, Yang J, He X, Zhang M. Diagnosis of pneumothorax by radiography and ultrasonography: a meta-analysis. Chest. 2011 Oct;140(4):859-866. PMID: 21546439

Additional Reading

  • Rizvi MB, Rabiner JE. Pediatric Point-of-Care Lung Ultrasonography: A Narrative Review. West J Emerg Med. 2022 Jun 5;23(4):497-504. PMID: 35980421
By |2023-08-08T23:52:38-07:00Aug 9, 2023|Expert Peer Reviewed (Clinical), Pediatrics, PEM POCUS, Radiology, Ultrasound|
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Trick of Trade: Dual Foley catheter to control massive epistaxis

Massive epistaxis is considered a medical emergency that requires immediate attention. Symptoms of massive epistaxis include sudden and heavy bleeding from the nose, difficulty breathing, dizziness, and a rapid heartbeat. If left untreated, it can lead to significant blood loss, shock, airway obstruction, and even death. We report a case of a 50-year-old man with end stage renal disease with massive nasal bleeding from the left nostril, shortness of breath, and confusion.

Initial Management

After a rapid assessment, we inserted an anterior nasal pack, soaked in epinephrine, TXA, and an antibiotic-based lubricant. However, the bleeding continued from his nares and posterior oropharynx. We thus removed the anterior packing and instead inserted a Foley catheter into the posterior nasal space and inflated the balloon. Unfortunately, the bleeding still continued. Because he presumably had uremia-induced thrombasthenia (weak platelets), he received blood transfusions and IV TXA. And still — he continued bleeding heavily.

Trick of the Trade: Dual Catheter Technique

To provide optimal surface area coverage and tamponade effect of the posterior vessels, concurrent anterior packing is usually needed [1]. You can use commercial devices that have a dual balloon setup, but we did not have that available.

dual balloon for massive epistaxis

Illustration by Dr. Abdelhameed with patient-consented photo of dual balloon technique

Technique

  1. Insert the a 14-French Foley catheter into the nares with the patient’s mouth open (balloon 1). Stop when you see the tip of the catheter dangling in the posterior oropharynx.
  2. Inflate the balloon partially with 15-20 cc of air.
  3. Gently pull the catheter anteriorly until you feel resistance such that the balloon is snuggly positioned.
  4. If the bleeding still continues, insert a second Foley catheter until you meet resistance (balloon 2). Inflate this second balloon with 15 cc of air.

For our case, this dual catheter compression technique succeeded in halting the bleed.

Interested in Other Tricks of the Trade?

Reference

  1. Goralnick E. Posterior Epistaxis Nasal Packing. Medscape. Published Dec 9, 2020
By |2023-05-23T23:11:19-07:00May 29, 2023|Genitourinary, Pediatrics, Tricks of the Trade|
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Trick of Trade: Removal of Entrapped Metal Zipper

zipper entrapment injury

A young boy is brought to the pediatric emergency screaming at the top of his lungs by his parents. His penile skin is trapped in the zipper of his jeans. On a busy shift, you want a simple way to handle zipper injuries that minimizes pain, doesn’t require resource-intensive procedural sedation, and is quick.

Background

The 4 most common types of zippers are nylon coil zip, plastic mold zip, metal zip, and invisible zip. Most of the techniques describing solutions on zipper entrapment in the medical literature are derived from case reports and case series. All revolve around understanding zipper anatomy and obtaining adequate exposure to assess how the skin is entrapped. The penile skin often is entrapped either in the sliding mechanism (also known as the endplate) or between the teeth of the zipper.

zipper anatomy

Figure 1. Anatomy of a zipper

Penile Entrapment Injury Management Techniques in Literature

Reported techniques for releasing zippers include [1, 2]:

  • Cut the sliding mechanism (aka the endplate) using metal cutters.
  • Use a flat screwdriver placed underneath the sliding mechanism and rotate it.
  • Use mineral oil for lubrication.
  • Use lateral compression technique to relieve the tension on the trapped skin.
  • Cut the zipper and pull the teeth apart.

All these techniques are associated with variable rates of success. Some of these techniques such as using metal cutters might lead to iatrogenic injuries.

The problem is that the child’s penile skin is entrapped within a metal zipper, where many recommended methods for zipper entrapment removal won’t work.

Trick of the Trade: Removing Metal Zippers

Materials Needed

  • Lidocaine gel
  • Blade or scissors

Technique

  1. The zipper should be separated from the pants as much as possible to minimize painful stretching or pulling of the penile skin.
  2. Apply lidocaine gel on the area of entrapment for 2-3 minutes.
  3. Identify the exposed teeth closest to slider and cut off the zipper at that level (blue dots) while avoiding penile skin (Figure 2).
  4. Gently advance the zipper body forward, pulling either the tab or the body itself, to disengage it from the teeth. You may need to add more lidocaine gel or other lubrication to facilitate this sliding motion.
  5. The remaining parts of the zipper can easily be disengaged from the skin (Figure 3).

metal zipper cut trick zipper entrapment

Figure 2. Cutting off the zipper between the teeth (blue dots) and advancing the zipper body (yellow arrow)

metal zipper entrapped free

Figure 3. Freed zipper body

Interested in Other Tricks of the Trade?

References

  1. Leslie SW, Sajjad H, Taylor RS. Penile Zipper and Ring Injuries. [Updated 2023 Mar 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
  2. Tasian GE, Belfer RA. Genitourinary trauma. In: Fleisher and Ludwig’s Textbook of Pediatric Emergency Medicine, 7th ed, Shaw K, Bachur RG (Eds), Lippincott Williams & Wilkins, Philadelphia 2015.
By |2023-05-23T21:20:02-07:00May 24, 2023|Genitourinary, Pediatrics, Tricks of the Trade|
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SAEM Clinical Images Series: A Rare Pediatric Scalp Rash

rash

The patient is a 3-month-old, full-term male who presents with a rash on his head. The rash started one day prior to presentation on his forehead and spread to the rest of his head. Today, it developed a central clearing with surrounding redness. He has a history of sensitive skin since birth with patches of eczema and cradle cap. He treats these with Aquaphor and Honest Co. Cream; he has never been prescribed topical steroids for his rashes. Denies fever, cough, rhinorrhea, congestion, decreased appetite, diarrhea, and decreased urination. He had an uncomplicated birth history.

General: Well appearing, no distress.

Skin: Large, serpiginous rash on the left forehead and scalp with central clearing and peripheral erythema as well as areas of erythematous plaques. He has some erythema of the left medial epicanthus. He also has a large erythematous patch at the base of his skull. The remainder of his skin is clear.

CV: Normal rate and rhythm, no murmur.

White blood cell (WBC) count: 8.4

Hemoglobin: 12.4

Hematocrit: 37.1

Platelet Count: 468

Complete metabolic panel (CMP): ALT 30, AST 60, Alk phos 266, Tbili 0.7, Total Protein 6.4

The image is of the cutaneous manifestation of neonatal lupus erythematosus. Neonatal lupus erythematosus is an autoimmune disease caused by transplacental passage of maternal autoantibodies to Sjögren’s syndrome A or B autoantigens (SS-A/SS-B). It can present with reversible changes including cutaneous lesions (most common, in up to 40% of patients), hepatobiliary disease, and cytopenias, which resolve once maternal autoantibodies have been cleared.

All infants that present with concern for neonatal lupus erythematosus should have screening labs performed to evaluate for hematologic, cardiac, and hepatobiliary involvement including a CBC with differential, liver enzymes, and antibody testing. In addition, an EKG is essential given that neonates can present with irreversible total atrioventricular heart block, which can present in utero or after birth.

The rash typically presents in the first few weeks of life but can present as late as 2-3 months of life (usually within 1-2 days of first sun exposure). Eighty percent of cases are not clear at birth and present in the first month of life. The rash appears as a coalescing rash with raised margins, with annular and discoid erythema involving the head in 95% of cases. It is often misdiagnosed as skin infections or eczema if the mom is asymptomatic. Fifty percent resolve by four months of life and 100% by one year.

Any neonate with a slow fetal heart rate or the postnatal diagnosis of atrioventricular heart block warrants immediate maternal testing for these autoantibodies. Most cardiac changes from neonatal lupus are diagnosed before 26 weeks gestation, with <20% later in pregnancy and 2% detected postnatally.

Take-Home Points

  • While cutaneous findings of neonatal lupus most commonly present in the first month of life, they can present as late as 2-3 months.
  • The cutaneous findings associated with neonatal lupus most of the time resolve in 4-6 months (when maternal antibodies are cleared from the infant’s circulation).
  • Any baby with findings concerning for neonatal lupus should have an EKG performed. Around 2% of infants present with heart block postnatally within the first month.

  • Diaz-Frias J, Badri T. Neonatal Lupus Erythematosus. [Updated 2021 Jun 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526061/
  • Lee LA. Neonatal lupus erythematosus: clinical findings and pathogenesis. J Investig Dermatol Symp Proc. 2004 Jan;9(1):52-6. doi: 10.1111/j.1087-0024.2004.00827.x. PMID: 14870986.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2021 SAEM Annual Meeting | Copyrighted by SAEM 2021 – all rights reserved. View other cases from this Clinical Image Series on ALiEM.

By |2023-04-05T14:00:29-07:00Apr 10, 2023|Dermatology, Pediatrics, SAEM Clinical Images|
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The Febrile Infant: Incorporating the 2021 American Academy of Pediatrics guidelines

Can you trust a febrile infant?

“No” has been, and continues to be, the resounding answer over the last 40 years as researchers and clinicians work to determine the optimal evaluation and management of the well-appearing young febrile infant [1].

The goal remains to identify infants with bacterial infections in this at-risk cohort of patients while also considering the balance of cost-effectiveness on a population scale and the potential for iatrogenic harm with evaluation such as unnecessary lumbar punctures, unnecessary antibiotics, and unnecessary hospitalization. Fortunately, bacteremia and bacterial meningitis in this age group are uncommon [2]. Unfortunately, delayed or missed diagnosis can be devastating [1-3].

In the most recent 2021 Clinical Practice Guideline, the American Academy of Pediatrics (AAP) aims to provide guidance with 3 separate age-based algorithms for the evaluation and management of the well-appearing febrile infant [4]. These guidelines were made possible by the recent PECARN, Step by Step, and other studies and the invaluable information they have provided [5-7].

Who’s included?

  • Well-appearing febrile infants
    • The AAP acknowledges that clinician experience is likely the best determinate of what is “well-appearing”, further admitting that there is no measure or definition of either “experience” or “well-appearing”
  •  Febrile
    • Rectal temperatures of  38.0C or 100.4F at home in the past 24 hours or determined in a clinical setting
    • Subjective fevers at home are excluded
  •  Gestation
    • Between 37-42 weeks
    • Premature infants excluded
  • Age
    • Days 8 to 60 and have been discharged home following birth

Who is not included?

  • Preterm or infants with congenital/chromosomal abnormalities
  • Infants with focal bacterial infections
  • Cellulitis, omphalitis, septic arthritis, osteomyelitis
  •  Bronchiolitis
    • With or without a positive RSV test
  •  Immunocompromised
    • Either suspected or known deficiency
  • Immunizations in the previous 48 hours

It should also be noted that the AAP has named the following as high-risk inflammatory markers that will be referenced in the soon-to-be-discussed guidelines [4,5].

  • Temperature >101.3F (38.5C)
  • C-reactive protein (CRP) > 20 mg/L
  • Procalcitonin >0.5 ng/mL
  • Absolute neutrophil count (ANC) >4000 mm3  (or 5200 mm3 if your facility does not have procalcitonin available)

The Groups

While the AAP makes the distinction of an age 0-7 days group from the age 8-21 days, they provide no specific recommendations about emergency department (ED) management in the youngest group [4]. Despite this, these infant groups are likely best evaluated and managed similarly in the ED:

  • Urinalysis (UA) +/- urine culture if indicated by UA
  • Blood culture
  • Lumbar puncture (LP)
    • Cell count, Gram stain, glucose, protein, bacterial culture, and enterovirus PCR (if available)
  • Admission

Inflammatory markers are not required to determine ED management in this age group but may guide inpatient clinicians.

Treatment

  • Ampicillin IV or IM
  • Ceftazidime IV or IM or gentamicin IV or IM

The addition of acyclovir to IV antibiotics depends on the following risk factors which increase the likelihood of HSV:

  • Maternal genital HSV lesions or fever 48 hours before or after delivery
  • Infants with vesicles, seizures, hypothermia, mucous membrane ulcers
  • CSF pleocytosis with a negative Gram stain result
  • Leukopenia, thrombocytopenia, or elevated AST/ALT levels

Although many febrile infants in this group will still require a full evaluation for sepsis, there are some new alternatives in patients meeting certain criteria. At the minimum, all 22-28 day old infants will need:

  • UA +/- culture
  • Blood culture
  • Inflammatory markers (ANC, CRP, procalcitonin)

Further management of a well-appearing infant in this group can be based on the following pathways:

    1. If UA positive with negative inflammatory markers
      • LP may be performed but is not required
      • IV antibiotics and admission are required regardless
    2. If UA negative with negative inflammatory markers, then there are 2 options
      • Perform LP
        • If LP negative, then the patient can be given a dose of parenteral antibiotics and discharged home with close follow-up in 24 hours.
        • If LP is traumatic or pleocytosis is present, administer antibiotics and admit.
      • Defer LP
        • Antibiotics may be administered, but the patient should be admitted.
    3. If UA negative and ANY positive inflammatory marker (procalcitonin > 0.5 mg/mL, CRP >20 mg/L, ANC >4000, or temperature >101.3F), LP is required
      1. If LP positive
        • Admit with IV antibiotics
      2. If LP negative
        • Admit +/- antibiotics, OR
        • Discharge home after one dose of parenteral antibiotic with 24-hour follow-up

Treatment

  • Same antibiotic options as the day 0-21 infants

The nuances of this group’s decision tree revolve around the inflammatory markers.

Each infant in this group should have the following completed:

  • Urinalysis
  • Blood Cultures
  • Inflammatory markers (CRP, ANC, and procalcitonin)

If everything is negative (UA & inflammatory markers):

  • Infants may be discharged home without antibiotics and with close follow-up within 36 hours.

If inflammatory markers are negative:

  • Infants with a positive urinalysis and negative inflammatory markers may be treated with oral antibiotics.
    • They may be either admitted to the hospital for observation or discharged with 24-hour follow-up.
    • No LP needed.

If inflammatory markers are positive:

  • A LP may be performed if the clinician feels it necessary but is not required.
    • If performed and CSF is negative the infant may be discharged with close follow-up.
    • Given high risk of bacteremia with elevated inflammatory markers in this age group, a dose of parenteral antibiotics prior to discharge is appropriate.
  • If LP deferred:
    • Administer parenteral antibiotics, and likely admit to hospital.
    • The caveat to this is if they have viral testing completed that is positive and are well appearing.
      • Example: A 48-day-old infant presents with a fever of 100.6F, CRP of 22 mg/L, and otherwise normal procalcitonin, ANC, and UA. The mother reports that an older brother has had a runny nose. Viral PCR testing is positive for rhinovirus. Seeing as the UA is negative, the infant appears well with a positive viral test, they may go home with shared decision-making and close outpatient follow-up, despite a positive inflammatory marker (CRP 22 mg/L) [3].

Treatment

Urinary Tract Infection:

  • Ceftriaxone (IV/IM) or cephalexin/cefixime as oral options.

Concern for Bacteremia/Meningitis:

  • Ceftriaxone + vancomycin
  • May add acyclovir for the above-mentioned antiviral treatment indications.

What should be done if the viral panel is positive?

  • Children 29 days or older with fever from a documented viral source can be managed according to their clinical presentation and can go outside the algorithm.
  • This requires a documented positive viral swab and not just a presentation consistent with a viral syndrome.
  • UTI is common in this age group, and a UA should be obtained [8].

Conclusion

Over the course of nearly the last half century there has been a lack of clear evidence-based guidelines in evaluating the young febrile infant [1]. Although serious bacterial infections in these young, febrile infants are uncommon, studies show that in the first month of life, bacteremia can be present in nearly 3% of febrile infants, with bacterial meningitis occurring in about 1% [2]. The absence of consensus regarding management has led to significant costs due to hospitalizations and their associated iatrogenic complications [9]. In the movement to create new recommendations, shifting epidemiology pushed changes in previous guidelines with a new focus on the use of the now widely available inflammatory markers [10].  With the advent of multiple large-scale studies and the recent improvements in lab testing, the newly updated AAP guidelines provide recommendations on how to manage this challenging population [4-7].

Take Home Points

  • These management strategies can only be used in WELL-APPEARING infants – if they’re ill-appearing, do a complete workup.
  • Evaluation of febrile infants 0-21 days remains the same – do everything (blood culture, UA +/- culture, LP with CSF studies), give antibiotics, and admit.
  • For those infants 22-28 days, get the UA, blood culture, and inflammatory markers to guide management.
    • Not all febrile infants in the 22-28 day subset need an LP, though it should still be obtained in certain clinical circumstances, and discussed between  provider and parents in other situations
  • In infants ≤28 days, a complete workup is still needed even if a viral source is present.
  • Febrile infants 29-60 days old may be sent home after a negative workup with close follow-up.

References:

    1. Roberts KB. Young, febrile infants: a 30-year odyssey ends where it started. JAMA. 2004 Mar 10;291(10):1261-2. PMID: 15010450.
    2. Biondi EA, Lee B, Ralston SL, et al. Prevalence of Bacteremia and Bacterial Meningitis in Febrile Neonates and Infants in the Second Month of Life: A Systematic Review and Meta-analysis.JAMA Network Open. 2019 Mar; 2(3). PMID: 30901044.
    3. Baker MD, Avner JR, Bell LM. Failure of infant observation scales in detecting serious illness in febrile, 4- to 8-week old infants. Pediatrics. 1990;85(6):1040–1043. PMID: 2339027
    4. Pantell RH, Roberts KB, Adams WG, et al. Clinical Practice Guideline: Evaluation and Management of Well Appearing Febrile Infants 8 to 60 Days Old. Pediatrics. 2021;148(2):e2021052228. PMID: 34281996
    5. Kuppermann N, Dayan PS, Levine DA, et al. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr. 2019;173(4):342-351. PMID: 30776077
    6. Gomez B, Mintegi S, Bressan S, et al. Validation of the “Step-by-Step” approach in the management of young febrile infants. The Journal of Pediatrics. 2016 Aug; 138(2):e20154381. PMID: 27382134
    7. Nguyen THP, Young BR, Poggel LE, et al. Roseville Protocol for the Management of Febrile Infants 7-60 Days. Hosp Pediatr. 2020 Dec 17:hpeds.2020-0187. PMID: 33334815
    8. Shaikh N, Morone NE, Bost JE, Farrell MH. Prevalence of urinary tract infection in childhood: a meta-analysis. Pediatr Infect Dis J. 2008;27(4):302-308. PMID: 18316994
    9. Coyle C, Brock G, Wallihan R, Leonard JC. Cost Analysis of Emergency Department Criteria for Evaluation of Febrile Infants Ages 29 to 90 Days. J Pediatr. 2021 Apr;231:94-101.e2. doi: 10.1016/j.jpeds.2020.10.033. Epub 2020 Oct 31. PMID:33130155.

    Milcent K, Faesch S, Gras-Le Guen C, et al. Use of Procalcitonin Assays to Predict Serious Bacterial Infection in Young Febrile Infants [published correction appears in JAMA Pediatr. 2016 Jun 1;170(6):624].JAMA Pediatr. 2016;170(1):62-69. doi:10.1001/jamapediatrics.2015.3210 PMID: 26595253

By |2023-04-09T20:40:05-07:00Mar 29, 2023|Expert Peer Reviewed (Clinical), Infectious Disease, Pediatrics, PEM Pearls|
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