Pediatric Emergency Medicine (PEM) Pearls
Created in 2015, this series is hosted by Dr. Jessica Chow and Dr. Josh Bukowski who are authors and editors for this series which focuses on evidence-based care in the realm of pediatric emergency medicine.
An 18-month-old female with no past medical history is brought in by ambulance after a motor vehicle collision (MVC) at highway speed, restrained in an appropriate car seat. Mom was also brought in after delayed extrication with an obvious femur deformity. EMS reports that the patient had emesis on the scene, was fearful but calm, and has been moving all extremities.
Vitals per EMS: HR 120, BP 100/60, RR 30, SpO2 99%, Temp 36.5 C
An intra-abdominal injury (IAI) is considered to be any radiographically or surgically apparent injury to an intra-abdominal structure (urinary tract, gastrointestinal tract, spleen, liver, pancreas, gallbladder, adrenal gland, vasculature, and fascia). An intra-abdominal injury requiring intervention (IAI-I) is any IAI that causes death or requires an intervention such as laparotomy, angiographic embolization, blood transfusion, or even admission for intravenous fluids .
Despite our curiosity and desire to diagnose all injuries, emergency medicine teams must focus on recognizing IAI-I and tailor their workup accordingly given the negative consequences of excessive workup and treatment of stable IAIs (e.g., unnecessary splenectomies, hepatectomies, increased length of stay, radiation, and increased medical costs/resources).
Although the incidence of pediatric blunt torso trauma in the United States was 110,525 cases in 2016, the prevalence of IAI has been quoted to be as low as 6.3%; more importantly, the prevalence of IAI-I is less than 2% . Non-pediatric level 1 trauma centers were more likely to use computed tomography (CT) in pediatric trauma patients compared to pediatric trauma centers, even after adjusting for injury severity .
The Pediatric Emergency Care Applied Research Network (PECARN) conducted a prospective study of over 12,000 children ages 0-18 years presenting to pediatric and general EDs with blunt torso trauma. Significant predictors of IAI-I were low GCS, abdominal tenderness, abdominal wall trauma, thoracic wall trauma, decreased breath sounds, and vomiting. The authors developed a prediction rule with a sensitivity of 97% (93.7, 98.9) and a negative predictive value of 99.9% (99.7, 1.00) . External validation had similar sensitivity (99% 96-100%) reinforcing the utility of this clinical decision rule (CDR) in identifying low-risk individuals and decrease the use of CT .
In comparison to other CDRs, this rule does not include a gestalt variable but outperforms clinical gestalt with a lower miss rate (6 compared to 23) . Of note, this prediction rule is not a two-way tool and was created only to determine individuals at low risk of IAI-I, rather than to assist providers in deciding who needs a CT scan.
Reviewing the cases missed by the prediction rule in the initial study, possible clinical findings that could be captured with adjuncts, such as labs and imaging, include:
No single test effectively screens for IAI-I or IAI, but additional testing can increase the index of concern in cases that already have a higher pre-test probability (individuals who have any of the variables factored into the prediction rule). The following adjuncts can be considered for children who are not deemed very low risk.
Focused Assessment with Sonography for Trauma (FAST)
Chest X-ray (CXR)
Returning to our case, findings of concern include her GCS of 13 and reported emesis. Although it was a high-speed MVC and may represent a more severe mechanism, this variable was not found to be a predictor of IAI-I and should not in isolation inform your evaluation of her abdominal injury.
Application of the PECARN CDR demonstrates that the patient is not at very low risk for IAI-I. Labs and a FAST are performed and medications are given for symptom control.
The patient’s results are:
On re-evaluation after ondansetron and acetaminophen, the patient has a GCS of 15 and is excitedly playing with her new teddy bear from the fire department while sipping apple juice. The patient is safely discharged home with her dad after a very frightening experience without unnecessary costs or radiation.
Fiona is a 6 year old female who presents to your emergency department after falling onto her left hand while racing on the playground. X-ray of the left upper extremity reveals a distal radius fracture with minimal displacement and angulation. You plan to place her arm in a splint and arrange for close orthopedic follow-up. The only problem: Fiona is in a lot of pain, especially with any manipulation of her arm, and Dad is worried that she will not be able to tolerate having a splint placed. You consider reaching for an intranasal medication to help Fiona feel more comfortable and to place the splint in a quick, efficient manner.
An 8-year-old is brought in by her parents with shortness of breath and wheezing. She’s been receiving her “rescue inhaler” at home and continues to have symptoms. You examine her and find that she has normal oxygen saturation, mild tachypnea and retractions, and diffuse wheezes. You think that she’s experiencing an acute asthma exacerbation. Given the current pandemic, and a recent report that administering nebulizer treatments to COVID-19 positive patients was correlated with transmission of COVID-19 to healthcare workers , what is the best way to treat the patient?
Paramedics bring in a 5-month-old boy in respiratory distress. He’s crying furiously and has normal tone and color. Thick, copious secretions are coming from his nose. He is tachypneic with diffuse wheezes, crackles, retractions, and nasal flaring. His respiratory rate is 70 and his oxygen saturation is 88% on room air. Would you order a chest radiograph (CXR) for this child?
CXRs are routinely obtained in adults with respiratory symptoms. Children, however, are more sensitive to radiation and can have multiple respiratory infections every year. CXRs can increase cost, length of stay, and may not always be necessary.
This post presents some guidelines on when (and when not) to get a CXR in pediatric patients.
Amoxicillin is a penicillin derivative antibiotic against susceptible gram positive and gram negative bacteria. It has reasonable coverage for most upper respiratory infections and is used as prophylaxis for asplenia and bacterial endocarditis. This post aims to demystify amoxicillin treatment for common pediatric infections.(more…)
Supracondylar humerus fractures are the most common type of elbow fracture in pediatric patients, most often seen in a fall on an outstretched hand (FOOSH) or a fall on a hyper-extended elbow.1,2 If there is no obvious fracture on x-rays, the patient may have an occult fracture; look for secondary radiographic signs including a posterior fat pad sign, an enlarged anterior fat pad or ‘sail sign’, or malalignment. Occult supracondylar fractures (those with initial normal radiographs that are later diagnosed in follow up) make up 2-18% of all the fractures we see in kids.3 When x-ray findings are nonspecific but the index of suspicion for fracture remains high, ultrasound may aid in your clinical decision making.(more…)
Fractures are a common sign of abuse. It is impossible to tell from an x-ray alone whether or not a fracture is due to abuse. Fractures of the extremities are the most common skeletal injury in children who have been abused and approximately 80% of fractures due to abuse occur in children under 18 months old.1 In non-mobile children, rib fractures, long bone fractures, and metaphyseal fractures have a high correlation with child abuse. An understanding of the motor development of young children can aid physicians in the identifying fractures due to abuse.