Infectious diseases seem to be omnipresent in the Ped ED and, thus, have their own dedicated Category of the PedEMMorsels. Additionally, unusual dermatologic eruptions are also quite prevalently encountered when caring for children (see Approach to Rash). While individually each category is fun to think about, the excitement more than doubles when they occur concurrently (perhaps I am being facetious). Let’s review Blistering Distal Dactylics! (say that 6 times fast in a row – I dare you)
Blistering Distal Dactylitis: What It Is
- Superficial infection of the distal finger (just like the name would imply)
- Tense bulla forms over the volar aspect / finger pad [Tessaro, 2016]
- May extend dorsally to the lateral nail folds.
- Oval shaped
- Erythematous base
- Often a singular lesion
- Filled with purulent material (yuk).
- Caused by:
- Group A Streptococcus pyogenes
- Most common pathogen
- Unclear how it causes bullae to develop
- Don’t forget other interesting Strep Infections:
- S. aureus
- Less common, but known to cause bullous disease (see Staph Scalded Skin)
- Multiple lesions may predict infection with S. aureus.
- Rarely is MRSA implicated. [Fretzayas, 2011]
- S. epidermidis
- Group B Streptococcus
- Typically affects kids 2 years to 16 years, but has been shown in children <2 years as well. [Lyon, 2004]
Blistering Distal Dactylitis: Ddx
- Herpetic Whitlow
- Bullous impetigo
- Insect bites
- Blistering disorders
- Dyshidrotic eczema
- Friction blisters and other mechanical irritants
Blistering Distal Dactylitis: Diagnosis It!
- Clinical diagnosis for the most part.
- Consider other etiologies like Herpetic Whitlow.
- May have concurrent infection at another remote site (ex, URI, pharyngitis).
- Multiple lesions suggests Staph as causative agent.
- Can confirm with testing:
- Gram-stain and culture of debris and fluid from blister.
- May perform rapid strep testing on fluid/debris. [Cohen, 2014; Wollner, 2014]
- Rapid Strep Test has similar test characteristics/performance as it does when applied to patients with pharyngitis.
Blistering Distal Dactylitis: Treat It!
- Local Wound Care
- No definitive recommendations for incision and drainage, but often the blister is unroofed to collect specimen. [Tessaro, 2016]
- Once unroofed, wet-to-dry dressings are appropriate.
- Systemic Antibiotics
- Coverage for strep and staph is paramount.
- Beta-lactamase-resistant antibiotic often selected.
- Empiric covered for MRSA is not likely beneficial at this point, but keep local resistance patterns in mind.
- 10 Day course often cited.
- Topical antibiotics alone are inadequate.
The evaluation of pediatric patients with rashes is a common occurrence in the Ped ED… and a common area of frustration for many of us (ok, maybe it is just me). We have previously covered an approach to the evaluation of the Pediatric Rash. We have also covered a variety of common causes of pediatric rashes (ex, Scabies, Tinea, Diaper Dermatitis and Molluscum) including eczema. While many of these conditions are simple nuisances, some can become more problematic. Let’s make sure we stay vigilant for Eczema Herpeticum.
Eczema Herpeticum: Basics
- Atopic dermatitis is an inflammatory skin disease
- The inflammatory states creates an impaired skin barrier
- The impaired protection increases risk for bacterial and viral infections
- Eczema herpeticum
- A HSV skin infection that occurs in patients with atopic dermatitis.
- Occurs in 3-6% of patients with atopic dermatitis.
- Can be due to HSV1 or HSV2, but also other viruses can cause it (ex, varicella, poxvirus)
- May occur with either primary or recurrent HSV infection. [Wollenberg, 2003]
- More likely to occur in those patients with:
- Extensive eczema skin involvement
- Early onset of eczema [Wollenberg, 2003]
- Eczema lesions on head and neck
- High IgE levels
- Children who are young (1 year or younger) or have systemic illness (ex, fever) are more likely to require hospitalization. [Luca, 2012]
- Fortunately, overall mortality is low. [Aronson, 2013; Aronson, 2011]
Eczema Herpeticum: Presentation
- Systemic symptoms
- Skin eruption
- Monomorphic eruption of dome-shaped vesicles
- Initially starts in region of eczema
- Can spread to involve normal skin also
- Lesions may crust and form superficial pits and erosions
- Head, neck, and trunk frequently affected.
- Lesions can affect the eye and cause keratoconjunctivitis.
- Fluid from vesicles can be sent for HSV PCR or viral culture to confirm diagnosis.
- May have bacterial infection superinfection
- S. aureus is commonly cultured (~30%). [Aronson, 2011]
- Septicemia cases can occur, but less commonly (~3%). [Aronson, 2011]
- Dissemination of HSV
- Multiple organ involvement
Eczema Herpeticum: Treatment
- Acyclovir is the traditional therapy
- Depending on severity of condition, oral or IV is appropriate
- Oral acyclovir has low bioavailability, so only use for mild cases.
- Delayed administration of acyclovir in hospitalized patients is associated with increased length of stay. [Aronson, 2011]
- Each day of delayed initiation of acyclovir increased LOS.
- Challenging to recognize, but important to consider and initiate therapy early, similar to neonatal HSV.
- Topical steroids
- Concern that topical steroids may increase spread of HSV infection.
- Topical steroids are not definitively associated with worsening disease and prolonged LOS. [Aronson, 2013; Aronson, 2011]
- May be prudent to wait until acyclovir has been initiated. [Aronson, 2011]
- Systemic steroids do worsen eczema herpeticum and increase LOS. [Aronson, 2013; Aronson, 2011]
- Empiric antibiotics for all kids have not shown to improve outcomes. [Aronson, 2013]
- Early recognition of serious bacterial infection is important, however.
Moral of the Morsel
- Most rashes in children are benign, but remain vigilant.
- Eczema injures one of the body’s primary defenses against the outside world, so always consider bacterial as well as viral super-infections.
- If you see blisters in child with eczema, think Eczema Herpeticum!
- Obtain HSV PCR and viral culture of fluid from blisters and initiate acyclovir.
Acute scrotal pain will always grab both patient’s and providers’ attention, appropriately. We have already discussed the most feared cause of acute scrotal pain – Testicular Torsion. While there are many other causes of inguinal and scrotal pain (ex, varicocele, inguinal hernia), one of the common causes is Torsion of the Appendix Testis.
Appendix Testis: What is that?
- There are actually 4 identified testicular appendages, but appendix epididymis and appendix testis or the most commonly encountered.
- Appendix testis is located in the groove between testis and the epididymal head at the upper pole of the testis.
- The appendix testis is pedunculate and susceptible to torsion.
- Torsion of the appendix testis is a common cause of acute scrotal pain in children. [Boettcher, 2013; Sakellaris, 2008]
Appendix Testis: Don’t Get it Twisted
- Etiology of torsion is unknown.
- Usually occurs in boys 7-14 years of age.
- More common than epididymitis in children.
- Torsion of the appendix testis can lead to necrosis of it.
- The necrotic tissue will lead to local inflammation and, thus, mimic epididymitis. [Boettcher, 2013]
- Inflammatory cells infiltrate the twisted appendix testis and are a marker of progression of the disease, not infection. [Rakha, 2006]
- Clinical History and Exam are helpful, but not conclusive
- “Classic” signs:
- Localized tenderness at the superior pole
- Blue Dot sign
- Preserved cremasteric reflex
- Findings that favor Epididymitis: [Boettcher, 2013]
- Painful epididymis
- Ultrasound can be helpful in making the diagnosis. [Lev, 2014; Yang, 2005]
- Findings consistent with torsion of appendix testis:
- Size of 5 mm or greater
- May see hyperechogenic mass between epididymal head and upper pole of the testis.
- Often associated with enlarged epididymis and hydrocele.
- Spherical shape
- Increased periappendiceal blood flow
- Findings more consistent with epididymitis: [Boettcher, 2013]
- Altered epididymal echogenicity
- Increased peritesticular perfusion on the affected side
- Often used as means to evaluate for testicular torsion.
- Ultrasound is not perfect in ruling-out testicular torsion.
- Recall that normal blood flow does not completely exclude the possibility of testicular torsion. [Sakellaris, 2008]
- Restricted activity (“Sorry, no soccer or football this weekend boy.”)
- Cool Sitz baths
- Antibiotics are not required.
- Obviously, this seems intuitive, but often the U/S may indicate findings consistent with epididymitis/orchitis so you may be inclined to give abx.
- Antibiotics for epididymitis can be reserved for boys with: [Boettcher, 2013; Halachmi, 2005]
- Recurrent infection history
- Underlying urinary tract abnormality
- Signs of puberty
- Very rarely will surgical excision be required for pain control.
We all know that airway management is a critical skill for those of us who care for pediatric patients in the acute environment! Due to conditions like severe respiratory illness (ex, asthma), acute trauma (ex, pulmonary contusion), or acute metabolic derangements (ex, DKA) children may benefit from endotracheal intubation. We must, however, remember, that in our efforts to help the child we must first do no harm, and the act of intubation has a large potential for inducing harm. One of the most important aspects of endotracheal intubation is proper positioning of the ETT. Let us take a moment to review Endotracheal Tube Depth.
Endotracheal Tube Depth: Do No Harm
- Unrecognized ETT misplacement (too high/too low) occurs frequently in Ped ED. [Miller, 2016]
- Low placement (i.e., mainstrem bronchus) is the most common misplacement!
- Younger patients and female patients are particularly at risk.
- Unrecognized ETT misplacement leads to complications!
- Inadequate / difficult ventilation
- Significant atelectasis
- Potential for unnecessary procedures (ex, misinterpretation of their being a pneumothorax leading to chest tube)
Endotracheal Tube Depth: Anticipate
- When planning to intubate, remind yourself of the proper positioning of the ETT
- Distal tip of the ETT should be between:
- The thoracic inlet and
- The carina.
- The ETT should be positioned and measured at the central incisor / alveolar ridge.
- Do not measure at the lip.
- Anticipate that this will be more challenging to achieve in children, particularly infants.
- Shorter tracheal length = less room for error
- The length from the vocal cords to the carina can vary between 5cm and 9 cm.
- Head / neck position plays a role!
- Neck extension will cause the ETT to move cephalad: potentially leading to extubation!
- Neck flexion will cause ETT to move toward carina: potentially going into mainstem bronchus!
Endotracheal Tube Depth: Estimate
- There are several formulas that can help estimate the depth in centimeters of the ETT.
- Personally, I am always a little leery any time there are multiple formulas to answer a question… (see Traumatic LP CSF Evaluation)
- Also, sadly, in the heat of the moment… doing complex calculus is not my strongest skill…
- Formulas can be useful to estimating initial tube placement, but their performance is variable for each individual patient.
- Age-based or height-based formulas are based on population statistics.
- Your individual patient may be outside the mean of that population!
- Most formulas are less accurate for children < 3 years of age. [Koshy, 2016]
- PALS Estimation
- For children > 1 year
- [Age (in years) / 2] + 12 (for oral ETT)
- Frequently leads to malpositioned ETT [Koshy, 2016; Lau, 2006]
- Internal Diameter Estimation
- 3 x ID of ETT
- Ex: 4.0 ETT => Depth = 12 cm
- Only used for ETT 3.0 or greater.
- Only predicted accurate placement in ~59% of cases. [Koshy, 2016]
Endotracheal Tube Depth: Auscultate?
- ETT placement confirmation has typically begun with auscultation of breath sounds.
- Equal / symmetric bilateral breath sounds would seem to suggest aeration from above the carina.
- The problem is that ETT’s with a Murphy eye can generate bilateral breath sounds even in the setting of a mainstem bronchial intubation.
- Bilateral breath sounds does not exclude mainstem intubation. [Verghese, 2004]
Endotracheal Tube Depth: Confirm!
- Chest Xray are traditionally used to confirm ETT position.
- Pros: CXR has been found to be superior to over formulas or other estimations. [Koshy, 2016]
- Cons: CXR is time consuming to obtain.
- Palpation of the trachea has been used to help determine ETT position. [Gamble, 2014]
- During intubation, another practitioner places 3 fingers on trachea with inferior finger at the sternal notch.
- The ETT is slowly advanced into the airway and positioned via external palpation.
- This was found to be superior to estimation formulas.
- Ultrasound can help you “see” the ETT position!
- An ultrasound probe positioned at the sternal notch can help locate the ETT. [Chowdhry, 2015; Chou, 2015; Tessaro, 2015]
- Much more readily available than CXR!
Moral of the Morsel:
- Your successful placement of the ETT through the cords is only the beginning of the airway management!
- Don’t celebrate too early! You have now placed the patient in a precarious position!
- Ensure that the ETT is appropriately positioned!
- Anticipate and Estimate, but Confirm!!!
- If there is any change in the child’s condition, Re-CONFIRM appropriate position of the ETT!
- Bring your Ultrasound to the bedside! Looking is better than listening!!
We know that children are super flexible and that is a good thing! Often kids will bend and won’t break! Unfortunately, there are events that still lead to childhood injuries. Some of these events are unfortunate and accidental (ex, Submersions), while others are sinister and purposeful (ex, Abuse). When we think of injury in children, we often immediately consider head trauma (the leading cause of mortality), but let us not overlook thoracic trauma as it is the second leading cause of mortality in children suffering from trauma. While pulmonary contusions are the the most common intra-thoracic injury, let’s spend a moment contemplating the significance of Rib Fractures.
Rib Fractures: Description
- 4 fracture types have been described. [Love, 2013]
- Sternal end
- 4 locations have been described. [Love, 2013]
- Rib fractures occur by 2 possible mechanisms:
- Anterior-posterior compression (most common)
- Direct trauma to rib surface
Rib Fractures: Age Matters
- Children have rib fractures less often than adults due to anatomic and structural differences.
- Rib morphology and orientation changes with age. [Weaver, 2014]
- Rib cage increases in size and decreases in kyphosis from birth to teen years.
- Ribs rotate inferiorly also.
- Ribs increase in roundness and horizontal angle with increased age.
- These changes influence risk for fracture with increasing age (particularly elderly patients).
- The thoracic cage is more compliant (more able to deform without fracture) in children.
- It takes a significant force to cause a rib fracture in a child.
- The complaint chest wall does not dissipate a force as well, transmitting more of it inward to the underlying organs (see Pulmonary Contusion).
Rib Fractures: The Concerns
- Abuse should always be on your radar!
- Most rib fractures in infants are caused by child abuse. [Bulloch, 2000]
- Other etiologies should be considered as well.
- Ex, Birth Trauma, Rickets, Osteogenesis Imperfecta
- Abused children have more rib fractures than accidentally injured children. [Darling, 2014]
- Accidental injuries cause more intrathoracic injuries, likely due to the mechanisms. [Darling, 2014]
- Lack of intrathoracic injury does not rule out abuse! [Darling, 2014]
- Concurrent extra-thoracic fractures where more common in abuse cases. [Darling, 2014]
- Rib fractures are associated with other injuries.
- Children have higher rates of associated head, thoracic, and solid organ injuries with rib fractures compared to adults. [Kessel, 2014]
- Rib fractures should be considered a sign of significant, possible multiple, trauma in kids.
- Mortality increases in a LINEAR fashion for each fractured rib in children. [Rosenberg, 2016]
- Adult mortality has a steep increase above 6 fractured ribs.
- In kids, mortality odds worsen with each rib fractured.
- Mortality increased from 1.79% without rib fracture to 5.81% with one rib fracture.
- With each rib fracture, mortality rate increased in nearly linear fashion up to 8.23% for 7th rib fractured.
Moral of the Morsel
- Highly consider abuse in children with rib fractures! May even want to consider extra thoracic injuries.
- Consider rib fractures as a indication of significant impact and trauma! Treat it like a risk factor for other occult injuries.
- Know that each rib fractured increases a child’s risk of mortality!