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.
Just as in adults, pediatric sepsis is a complex topic with continued research. In the United States, there are an estimated 75,000 cases per year of pediatric severe sepsis with an in-hospital mortality of 5-10%.1,2 This is one of the deadliest conditions treated in children. In addition, after the Rory Staunton case, New York State passed regulations requiring all hospitals to have pediatric specific recognition, treatment, and data reporting systems. Several other states have adopted, or are considering, similar requirements. Thus it is critical that emergency physicians understand at least the basics of pediatric sepsis management.
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
A 2-month old boy was brought in by his mother after an episode of the child’s face turning blue and a pause in breathing. Mom reports this lasted a few seconds. The mother was terrified, so she brought the baby to the ED.
Sometimes infants briefly stop breathing or go limp. How do we determine if an infant is low-risk for serious illness? Earlier last year, the American Academy of Pediatrics (AAP) released guidelines on the evaluation and management of Brief Resolved Unexplained Events (BRUE, replacing a 30-year old label “apparent life-threatening event” or ALTEs).1
A lumbar puncture (LP) is a common procedure that every emergency physician must master. Pediatric LPs can be challenging for even the most experienced clinician due to small anatomy, difficulty with patient cooperation, and lack of frequency performed. A successful procedure is defined by obtaining cerebrospinal fluid and/or performing a non-traumatic lumbar puncture. There are multiple variables that lead to a successful pediatric lumbar puncture including provider experience, use of anesthesia, and patient positioning. Success rates for pediatric lumbar punctures are variable, with a large range from 34%-75%.1
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?