What toxic substance found in common houseplants (such as this one pictured) causes intense irritation of skin and mucous membranes?
[Left image from Dr. Bryant Allen, MD, and right image from AJ West -Wikimedia Commons]
Which of the following chronic exposures could produce lesions such as this on the hands, feet, and trunk?
[Image from Wikimedia Commons]
What is this pictured spider that can inflict a deadly bite?
[Image from thebeachcomber, CC BY 4.0 https://creativecommons.org/licenses/by/4.0, via Wikimedia]
With some things in life, speed is everything. Adenosine is one of those things. With an ultrafast half-life estimated to be between 0.6 to 10 seconds [1], parenterally administered adenosine needs to reach the cells of the AV-node and cardiac pacemaker cells in an expedited fashion to facilitate the termination of supraventricular tachycardias (SVTs).
Currently, there are 2-syringe and 1-syringe methods that are widely accepted for the administration of adenosine. Recent data suggests that they are non-inferior to each other [2].
Classic 2-syringe method: Benefit = undiluted adenosine to the heart; Limitation = limited by the syringe flush volume [3]
1-syringe method: Benefit = large volume; Limitation = dilution of adenosine with IV fluid. Read more about the single syringe trick of the trade.
We propose administering undiluted adenosine in an ultra-rapid fashion via an in-line, primed saline tubing with a pressure bag setup.
The unique aspect of the trick is to incorporate a high-pressure, unidirectional IV fluid administration system. It is similar to the 2-syringe system except that the flush syringe is replaced with high-pressure IV fluids.
In this video, adenosine is the colored fluid for demonstration purposes. Notice how quickly the adenosine reaches the patient.
A 6-year-old female with a past medical history of immune thrombocytopenia presents to the Emergency Department (ED) for concerns of dysarthria that started the day prior to arrival. The patient’s mother denies any recent trauma, including head injury.
Her physical exam is remarkable for a mild right-sided facial droop with forehead sparing and dysarthria.
The patient’s ED workup shows the following:
Although rare, pediatric intracranial hemorrhage (ICH) contributes to almost half of all childhood strokes and can cause lifelong disability and death [1]. One 3-center prospective study on pediatric ICH noted a 9% mortality rate with ⅓ of survivors having “significant disability” at 2-year follow-up [2]. Primary predictors of adverse outcomes from pediatric ICH involve the following [2-4]:
Multiple studies consistently point to vascular causes such as arteriovenous malformation as a leading risk factor for spontaneous pediatric ICH followed by hematological pathologies including coagulation deficiencies [5-7]. No matter the cause, the sequelae of pediatric ICH can be devastating making early detection and immediate intervention essential for better outcomes. Unfortunately, given children often present with vague and non-specific symptoms, there is often a delay in presentation to care and in diagnosis [8]. Unfortunately, in contrast to adults, there are no set guidelines for the management of pediatric ICH despite its associated morbidity and mortality.
Although headache is the most common presenting symptom, other symptoms can vary [6,8,9]. In one study, children <6 years old were more likely to present with symptoms such as seizures and altered mental status, while children ≥6 years presented more with focal deficits, headache, vomiting, and altered mental status [9].
| Presenting Symptom/Finding | Incidence |
|---|---|
| Headache | 46-80% |
| Vomiting | 21-64% |
| Altered mental status | 37-50% |
| Seizures | 37-54% |
| Focal deficits (hemiparesis and aphasia) | 16-50% |
Given how rare pediatric ICH is, consider other diagnoses when a patient presents with focal deficits, altered mental status, and/or vague symptoms such as headache and weakness.
Emergency medicine physicians should have strong suspicion for ICH particularly in the setting of a pediatric patient presenting with acute onset of headache, vomiting, altered mental status, seizure, and/or focal deficits.
If a patient has a confirmed ICH, consultation with neurosurgery is required. Immediate transfer may be necessary if your facility does not have neurosurgical services. Further management includes:
The patient was transferred to a tertiary care center. Further imaging confirmed an intraparenchymal hemorrhage in the left frontal lobe and right parietal lobe with midline shift. No underlying lesions or vascular malformation were seen.
Management: The patient was admitted to intensive care and received tranexamic acid and a platelet transfusion. She was monitored by neurosurgery but no surgical interventions were needed. For her idiopathic thrombocytopenia, she received steroids and IV immunoglobulin.
Hospital Course: Her deficits and platelet count improved during her stay, and she was discharged on hospital day 5 with outpatient neurology and hematology follow-up.
Outpatient: Repeat imaging 3 weeks after discharge showed resolution of the midline shift and decrease in hemorrhage size.
Read more pediatric EM blog posts in the PEM Pearls series.
For years, adult literature has provided clear guidelines for cervical spine imaging through the NEXUS and Canadian C-spine Rule (CCR) tools. These have been invaluable in helping clinicians decide when to image the neck in trauma patients. Similarly, the Pediatric Emergency Care Applied Research Network (PECARN) has developed robust tools for assessing blunt head trauma in children. However, until now, there has been a gap in guidance for clinicians managing pediatric patients at risk for cervical spine injuries.
A 10-year-old boy presents to the emergency department (ED) after a high-speed motor vehicle collision. He complains of neck pain and is reluctant to move his head. The child’s mother is extremely worried, fearing the worst after witnessing the collision.
Cervical spine injuries in children, while uncommon, can be devastating if not identified and treated promptly. Emergency physicians often face the challenge of deciding whether to proceed with imaging, given the potential risks associated with ionizing radiation from CT scans. The lack of clear guidelines specifically tailored for pediatric patients has historically led to either overuse of imaging, with its associated risks, or underuse, with the risk of missed injuries.
On June 4, 2024, Lancet published “PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study.” This study proposes a new clinical prediction rule to guide imaging decisions for pediatric cervical spine injuries.
The study enrolled 22,430 children, aged 0–17 years, presenting with blunt trauma across 18 PECARN-affiliated ED in the US. About half were in the derivation and half in the validation cohort. The researchers derived and validated a clinical prediction rule using data from these children, which identified key risk factors for cervical spine injury, divided into high-risk and non-negligible (intermediate) risk factors.
PECARN Cervical Spine Injury Prediction Tool (Download full sized PDF at PECARN site)
The prediction rule had strong test characteristics with 94.3% sensitivity and 99.9% negative predictive value, indicating that it can reliably identify children who do not need imaging, thus avoiding unnecessary radiation exposure. This evidence-based approach to pediatric trauma care would have reduced the number of CT scans by more than 50% without missing clinically relevant injuries.
Using the PECARN cervical spine injury prediction rule, the attending physician evaluates the boy and finds that he does not exhibit any high-risk factors. However, because he reports neck pain and has midline neck tenderness on exam (intermediate risk), the rule recommends that the cervical spine can not be clinically cleared. It also suggests plain x-rays and not a CT scan. This differs from the adult population whereby CT scan imaging is often the first choice for diagnostic testing.
The x-rays reveal no evidence of cervical spine injury, and the boy is cleared with instructions for follow-up care. This approach not only alleviated the mother’s anxiety but also avoided unnecessary radiation exposure for the child.
Leonard JC, Harding M, Cook LJ, et al. PECARN prediction rule for cervical spine imaging of children presenting to the emergency department with blunt trauma: a multicentre prospective observational study. Lancet Child Adolesc Health. 2024;8(7):482-490. doi:10.1016/S2352-4642(24)00104-4. PMID 38843852
What caustic exposure from the pictured item can lead to ocular injury?
[Image from Istockphoto]