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.
Pain and anxiety in the emergency department (ED) are two of the most common things we see in children. Pediatric patients, whether first time visitors or those with chronic illnesses, can exhibit marked anxiety and fear when in the ED setting. Child development, parenting styles and prior medical experiences will guide their reactions in these cases. Practitioners must have a unique set of tools to work with these children and understand the optimal methods for providing care, while decreasing some of these normal reactions to a stressful environment. The most important part of treating anxiety and fear in children is recognizing it early. While pharmacologic interventions can adequately treat pain and anxiety in children, there are quick and effective approaches to avoid these medicines in many cases. Below is a structured approach to assess and reduce anxiety during examination:
A 10-year old girl presents with progressively worsening right lower quadrant pain for the last 2 days. She reports having chills and feeling warm. Her review of systems is negative for nausea, vomiting, diarrhea, or urinary symptoms. Her abdominal exam is unremarkable except for some diffuse, mild tenderness with deep palpation in bilateral lower quadrants. Labs: WBC 9 x 10^9/L. Because of radiation exposure concerns, you order an abdominal ultrasound as the initial imaging modality to evaluate for appendicitis. The radiologist’s reading was: “Unable to visualize the appendix.” Now, what do you do?
Febrile pediatric patients are ubiquitous in emergency departments (ED) around the country. Parents agonize over the presence, height, and persistence of fever, despite the energy we invest in attempting to reassure them and minimize ‘fever phobia’. But when should we, as providers, also be worried? Very often in pediatric patients we are trying to distinguish self-limited viral infections from potentially harmful bacterial ones. In ill-appearing patients, it’s easy. We treat the patient aggressively as if their symptoms were attributable to a bacterial infection. The proper approach is more opaque with the relatively well-appearing febrile child. How do we pick out the bacterial infections in these cases?
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
A 9-year boy was hit in the head during a soccer game and was out for a few seconds. He regained consciousness quickly, but was repetitive for EMS. By the time the patient arrived at the ED, he was back to his normal self. Did this patient sustain a concussion? If so, what discharge instructions, anticipatory guidance, and resources do you have for your patient and his family? Here’s a quick 170-second animated video tutorial to sum up some thing for you.
The Case: A 5 year old girl presents to the ED with approximately 24 hours of suprapubic and RLQ abdominal pain. Vital signs are: Temp 38.2 C, HR 110, RR 19, BP 100/60, Oxygen Sat 100% on room air. She has vomited twice but has not had diarrhea. She had a history of constipation a year ago that has resolved and mother denies any urinary symptoms or history of UTI’s. The patient is quiet but nontoxic appearing. Your abdominal exam notes mild to moderate RLQ tenderness but no rebound and normal bowel sounds. You order a urinalysis, which is negative and a RLQ US which ‘does not visualize the appendix’. Your suspicion for possible appendicitis is still intermediate; however, now the patient states she is “a little hungry”. Should you order a CT of the abdomen and pelvis? Uuugh!(more…)
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?