Within the PedEM Morsels, we have addressed many topics that involve fluid management. We have discussed the importance of considering glucose in all of your patients. We have also entertained the possibility of using hypertonic saline in critically ill patients. As dehydration is a constant concern, we have contemplated means to successfully manage this state as well, often without an IV. That being said, intravenous fluid administration is still required at times. Most often in the ED, it is done as boluses of isotonic fluids, but some will require maintenance fluids. Seems simple enough… but are we choosing the correct maintenance fluid?
Maintenance Fluids: Why This Matters
Intravenous fluids should garner the same respect as any other medication.
- Maintenance fluids are often required to replace expected daily loses.
- They are not meant to replace deficits (ex, hypovolemia).
- If there are deficits, maintenance should be added to the fluids that replace the deficit.
- Obviously, intravenous fluids, even maintenance fluids, can lead to harm:
- Volume Overload
- Electrolyte Abnormalities
- Hyponatremia is the most common electrolyte derangement found in hospitalized children.
- This is particularly true in post-operative patients.
Maintenance Fluids: What I Was Taught…
- Maintenance fluids are calculated based on expected energy expenditure.
- Holliday & Segar helped describe the rationale for this process in 1957: [Holliday, 1957]
- Caloric expenditure for the average child can be based on body weight.
- Up to 10 kgs: 100 calories/kg/day
- 10-20 kgs: 1000 calories + 50 cal/kg/day
- >20- kgs: 1500 calories + 20 cal/kg/day
- For every 100 calories burned, there is ~100 mL of water lost.
- This is the basis of the “4-2-1” rule for determination of volume.
- 4 mL/kg/hr for first 10 kg, then additional…
- 2 ml/kg/hr for every kg between 10-20 kg, then additional…
- 1 ml/kg/hr for each kg above 20 kg.
- The daily maintenance calculation is based on the same rationale, but generates slightly different hourly rates (nothing is perfect).
- Electrolytes need to be added to maintenance fluids based on energy expenditure as well:
- Sodium – 3 mEq per 100 calories
- Potassium – 2 mEq per 100 calories
- Chloride – 2 mEq per 100 calories
- Simple math will generate recommendations for both volume and tonicity of the maintenance fluids.
- Often this leads to prescribing ¼ NS or ½ NS (which, by the math, makes sense).
- Unfortunately, we know that hypotonic maintenance fluids are associated with greater risk for hyponatremia. [Ramanathan, 2015; Foster, 2014; Choong, 2011; Rey, 2011; Hanna, 2010; Beck, 2007]
Maintenance Fluids: Don’t Underestimate ADH’s Power
- Naturally, ¼ NS and ½ NS have been used for decades and not every patient is becoming hyponatremic and the rationale described originally is still valid, so it is obviously more complicated.
- One significant confounder in this system is Anti-Diuretic Hormone (ADH).
- Elevated ADH will lead to less free water excretion and, thus, the hypotonic maintenance fluids will generate hyponatremia.
- ADH secretion is stimulated by numerous factors and clinical states, like:
- Pain / Stress
- Respiratory distress / failure
- Head Trauma
- CNS infections
- Hypovolemic states
- Medications (ex, opiates, SSRIs, NSAIDs, Phenothiazines)
- Original, theoretical assumptions may be correct in theory, but in practice, the system is more complex.
Maintenance Fluids: Moral of the Morsel
- Iatrogenic fluid and electrolyte derangements are a significant hazard of intravenous fluids.
- Ask yourself whether you actually need the IV fluids in the first place!
- If giving fluids, realize that 4-2-1 rule is a starting point for maintenance volume… monitor urine output and tailor calculations for the individual.
- Favor Isotonic Fluids for Maintenance initially!
- This is especially true for pre/post-operative patients or patient in whom there is risk for them having elevated ADH levels (so, like all of the ones who need an IV in the hospital).
- Using Isotonic Fluids for Maintenance has proven to be safe [Friedman, 2015], while Hypotonic Fluids have greater risk for hyponatremia.
- As with the maintenance volume, the electrolyte composition should be tailored for the individual and monitored closely. Don’t let fluids be on “auto-pilot.”
Lee JM1, Jung Y, Lee SE, Lee JH, Kim KH, Koo JW, Park YS, Cheong HI, Ha IS, Choi Y, Kang HG. Intravenous fluid prescription practices among pediatric residents in Korea.
Korean J Pediatr. 2013 Jul;56(7):282-5. PMID: 23908667
. [PubMed] [Read by QxMD]
“Rash.” Certainly, this is not a favorite chief complaint in the Ped ED, but unquestionably it is a common one. While there may be very few “rash emergencies,” there are several significant conditions to ponder (ex, Kawasaki, ITP, HUS) as well as less concerning ones (ex, Molluscum). Additionally, before you dismiss the condition as being “not an emergency,” consider that there may be some helpful advice that you can provide. Often, a few tactful reminders and tips can lend comfort. Let us consider the most recent update [Eichenfield, 2015] on the seemingly ubiquitous Atopic Dermatitis.
Atopic Dermatitis: Basics
- In the US, estimated to affect ~12.5% of pediatric patients!
- No lab test to make the diagnosis.
- Combination of symptoms and findings:
- Relapsing and/or Chronic Pruritic dermatitis
- Distributed on face, neck, extensor surfaces as well as flexural folds.
- Erythematous papules and patches
- Dry skin (xerosis)
- Generally, spares the groin and axilla
- Consider other conditions that may mimic appearance:
- Seborrheic dermatitis
- Contact dermatitis
- Photosensitivity dermatitis
- Immune deficiency disease
- Cutaneous T-Cell lymphoma
Atopic Dermatitis: Severity
Generally speaking, these are not very distinct classifications and make intuitive sense, but are most useful in helping to determine appropriate care.
- Involves less body surface area
- Have less exacerbations
- Has less itch
- Moderate – Severe
- Involves greater amount of body surface area
- More persistent symptoms
- More severe itch
- Often require maintenance medications to help manage.
- Like with persistent asthma, “controller” medications can be helpful to manage mod-severe atopic dermatitis.
- Ex: Tacrolimus and/or Low-Medium potency topical corticosteroids used twice weekly.
Atopic Dermatitis: Routine Management
- Basic skin care is integral in the management of atopic dermatitis.
- These should be re-emphasized for all patients presenting with complaints consistent with atopic dermatitis. [Eichenfield, 2015]
- Skin Hydration
- Skin moisturizers used liberally and frequently even to uninvolved skin.
- Lotions actually can be drying.
- Favor ointments over lotions.
- Using mild soaps and apply skin moisturizers when still damp (after bathing).
- Antiseptic Measures
- Dilute bleach baths twice weekly (more frequently for those with recurrent skin infections) can help decrease risk of skin infections and decrease atopic dermatitis severity. [Huang, 2011; Huang, 2009]
- ~0.5 cup of sodium hypochlorite diluted in 40 gallons of water (1 full bath tub)
- Trigger Avoidance
- Trigger identification can be challenging, but is also very helpful (just like for any other atopic condition).
- Some common triggers: soaps, wool and abrasive clothing, lotions, fragrances, tight fitting clothing, food allergens and extremes in temperatures/humidity.
Atopic Dermatitis: Acute Therapy
- Topical corticosteroids
- For patient’s with Mild Disease
- Low potency corticosteroids twice daily for up to 3 days beyond improvement.
- Apply only to area involved with flare.
- Ex: Hydrocortisone ointment, dexamethasone cream
- For patient’s with Mod-Severe Disease
- Medium potency corticosteroids twice daily for up to 3 days beyond improvement.
- Apply only to area involved with flare.
- Ex: Triamcinolone ointment, Fluticasone ointment
- Consider possible secondary skin infection as well.
- Reinforce the need to continue with the Routine Skin Care above.
- May refer to other educational resources, like nationaleczema.org.
Sidbury R1, Tom WL2, Bergman JN3, Cooper KD4, Silverman RA5, Berger TG6, Chamlin SL7, Cohen DE8, Cordoro KM6, Davis DM9, Feldman SR10, Hanifin JM11, Krol A11, Margolis DJ12, Paller AS7, Schwarzenberger K13, Simpson EL11, Williams HC14, Elmets CA15, Block J16, Harrod CG17, Smith Begolka W18, Eichenfield LF2. Guidelines of care for the management of atopic dermatitis: Section 4. Prevention of disease flares and use of adjunctive therapies and approaches.
J Am Acad Dermatol. 2014 Dec;71(6):1218-33. PMID: 25264237
. [PubMed] [Read by QxMD]
Fever is one of the most common chief complaints in the Peds ED. We are all very accustomed to the common considerations (ex, UTI, Croup, Bronchiolitis, Appendicitis, and Sinusitis). We also know there are “zebras” that may try to trample us (ex, Kawasaki’s, Myocarditis, Osteomyelitis, Acute Rheumatic Disease, Lemierre’s, and Cat Scratch Disease). Additionally, we are aware of how important it is to avoid the “It’s Just a Virus” statement. On occasion though, the cause of the fever will not be clear, but the prolonged fever warrants concern. Let us, now, look at Fever of Unknown Origin.
Fever of Unknown Origin: Basics
- Often confused with “Fever Without a Source”
- Fever of Unknown Origin involves a prolonged duration of fever.
- Fever Without a Source may become Fever of Unknown Origin, if it lasts long enough.
- The exact incidence of Fever of Unknown Origin is not well defined.
- There is no standard definition.
- The ability to determine etiologies has improved over time.
- If a diagnosis is eventually determined, then it is no longer of “Unknown Origin.”
- Generally requires a duration of fever that is deemed to be excessively long for what was expected.
- Historically, up to 3 weeks of fever was used. [Petersdorf, 1961]
- Now, fever lasting longer than 8 days without a source is often cited.
- Ideally, there are documented fevers (38.0 C; 100.4 F).
- The Big Categories of Potential Causes to Consider:
- Infectious – ~30%
- The proportion of infectious causes has decreased in recent years, likely due to improved diagnostic testing.
- Rheumatologic / Autoimmune– ~20%
- Oncologic – ~10%
- Other Zebras – ~5%
- Familial Dysautonomia
- Periodic Fever Syndromes
- Cyclic Neutropenia
- Drug Fever – ~5%
- Often overlooked [Antoon, 2015]
- First step in evaluation is stopping all nonessential medications [Antoon, 2015]
- Many agents, including ibuprofen and acetaminophen, can be a source of drug fever.
- Undiagnosed (often spontaneously resolved) – ~30%
Fever of Unknown Origin: ED Considerations
- Do not under-appreciate the family’s concern
- Once we hear that the fever has been present for “2 weeks straight” we may “roll our eyes” internally and immediately think that this is no longer an emergency. Refrain from this (particularly if you tend to show your inner thoughts readily on your face).
- This goes along with never saying that it is “just a virus.”
- General Appearance: Is the child sick or not sick?
- Sick – Higher risk for badness and you should have lower threshold for hospitalizing.
- Not Sick – Lower risk for badness (not no risk), but likely more appropriately evaluated as an outpatient.
- The diagnosis is likely hiding in the History and Physical. [Tolan, 2010]
- Instead of ordering a ton of random tests, ask more questions... even the same ones over again (we have all witnessed “historic alternans”).
Additional historic details to obtain:
- Ethnic Background
- Travel history and prophylaxis
- Animal exposures – cats? petting zoos? etc.
- Vector exposures – ticks?
- HIV and TB risk factors
- Pica and Dietary exposures
Physical exam aspects to include:
- Look first for Disguised Horses rather than Zebras
- More likely to be dealing with an unusual presentation of a common condition than a common presentation of an unusual condition. [Antoon, 2015]
- Consider Pseudo-Fever of Unknown Origin
- Series of benign, self-limited illnesses over a short period of time [Tolan, 2010]
- Kids love to get another viral illness just as they are getting rid of one. This can create the appearance of the child being sick over a protracted course.
Fever of Unknown Origin: Work-up
- The differential for Fever of Unknown Origin is vast, but resist the urge to order every test available in your hospital.
- Broad laboratory testing is often more harmful than helpful.
- The history and physical are the foundation for your Ddx development and subsequent testing strategy.
- There are some basic tests that are supported by experts and may be useful in your ED to help sort through the Ddx: [Antoon, 2015]
- CBC w/ Diff – yes, I know that the WBC count is the “last bastion of the intellectually destitute” (Amal Matt, MD), but ensuring that it is not 125,000 is helpful… plus Hgb and platelet counts are helpful. [Chow, 2011]
- U/A and UCx
- Radiographs as indicated
- Additional testing:
- Likely appropriate for outpatient evaluation
- Limit unnecessary testing
- Arrange for serial examinations and have family keep fever journal.
- Blood Cultures
- CSF Cultures – if neurologic symptoms present
- ESR and CRP – have limited value in isolation, but may be helpful to track over time. Normal values do NOT rule-out serious conditions.
- Categorical Based Evaluations: (likely to be ordered by inpatient team)
- Serial Cultures if considering endocarditis
- Specific antibody and viral testing (ex, EBV)
- Uric Acid
- Peripheral Smear
- ANA, RF
- C3, C4, CH50
- Thyroid function panel
- CRP, ESR, ferritin
- Lymphocyte markers
- Antibody titers
Fever of Unknown Origin: Empiric Antibiotics?
- Ill Appearing?
- Then have a lower threshold for obtaining cultures and starting empiric antibiotics.
- Well Appearing?
- DO NOT give antibiotics!
- In developed countries, the rates of infectious etiologies of Fever of Unknown Origin have been decreasing.
- Empiric antibiotics can delay the diagnosis of many conditions like osteomyelitis and endocarditis. [Antoon, 2015; Chow, 2011]
Syncope is a rather common presentation in the Pediatric ED. While the etiology is most often a benign one, our vigilance assists us in detecting some of the more concerning entities. Yes, the episode may have been caused by Hair-Grooming, but we are on guard against Prolonged QTc, Catecholaminergic Polymorphic VTach, Seizures, and even Eating Disorders. While juggling these ominous entities, let us not overlook the potential for Brugada Syndrome.
Brugada Syndrome: Basics
- Potentially lethal channelopathy that is associated with VTach or VFib
- Inheritance: Autosomal Dominant
- Second leading cause of death in young Thai men (#1 is trauma).
- Likely expressed with incomplete penetrance.
- Typically presents in young adulthood, but it does occur in children.
- Regarded as a rare entity, but…
- It has only been recognized for past 30 years, so we are still learning about it.
- True incidence is not known as it is difficult to diagnose.
- The ECG findings may not always be present
- The specific genetic tests are abnormal in only ~1/3rd of cases
- May eventually be found to be “subtle and difficult to diagnose,” rather than rare. [Crosson, 2015]
Brugada Syndrome: Diagnosis
- Diagnostic Criteria are the same for adults and children. [Crosson, 2015]
- 3 types of ECG changes:
- Type 1
- “Coved” ST Elevation with at least 2 mm of elevation in at least 1 right precordial lead
- Only pattern considered diagnostic!
- Can be spontaneous or induced during provocative testing
- Type 2
- Saddle-back ST elevation
- Should consider diagnosis in the right clinical setting
- Type 3
- Saddle-back ST pattern without significant elevation
- Should consider diagnosis in the right clinical setting
Brugada Sign Types from http://circep.ahajournals.org
- May be asymptomatic upon initial evaluation.
- Consider with:
- Often occurs while at rest or with fever!
- Nocturnal agonal respirations
- Family history of Sudden Cardiac Death
- Family history of SIDS
- Family history of Type 1 ECG findings
- Self-terminated polymorphic VTach
Brugada Syndrome in Children
- True incidence suspected to be less than in young adults, but not fully known.
- Conduction delays are common in pediatric cases. [Chockalingam, 2012]
- Children are less likely to have Brugada ECG Pattern.
- Children are less likely to have symptoms.
- Children are more likely Monomorphic VTach (compared to VFib in older patients).
Brugada Syndrome: Treatment
- Management is tailored for each individual case.
- Determining risk factors for who with Brugada is at risk for developing fatal arrhythmia is still debated.
- Currently the best known therapy is AICD.
- Children have greater rate of AICD complications, so often reserved for severe cases. [Chockalingam, 2012]
- Asymptomatic patients or those with positive genetic testing or drug-induced Type 1 may be monitored closely, particularly during febrile illnesses.
- Quinidine – adjunct to AICD
- Fever Control
- Febrile illnesses have been shown to trigger events in children [Kim, 2014; Chockalingam, 2012; Zaidi, 2010; Probst, 2007]
- That child who had a syncopal event and is noted to be febrile deserves attention!
Probst V1, Denjoy I, Meregalli PG, Amirault JC, Sacher F, Mansourati J, Babuty D, Villain E, Victor J, Schott JJ, Lupoglazoff JM, Mabo P, Veltmann C, Jesel L, Chevalier P, Clur SA, Haissaguerre M, Wolpert C, Le Marec H, Wilde AA. Clinical aspects and prognosis of Brugada syndrome in children.
Circulation. 2007 Apr 17;115(15):2042-8. PMID: 17404158
. [PubMed] [Read by QxMD]
Performing a lumbar puncture in the ED is certainly a task with which we are very familiar. We have discussed potential reasons to perform a lumbar puncture (ex, Headaches, Pseudotumor cerebri, and Mollaret’s Meningitis). We have also covered strategies to make your first attempt you best attempt as well as what to do when the tap is traumatic. Now let us consider the potential for complication from your lumbar puncture: Post Lumbar Puncture Headache.
Post Lumbar Puncture Headache
- Post Lumbar Puncture (AKA, Post Dural Puncture) Headache is one of the most common complications of the LP.
- Several proposed mechanisms exist, but often thought to be due to continued CSF leakage through a dural tear.
- Studies including adult patients have shown incidences of around 1/4th of cases,but also as high as 1/3rd of patients. [Khlebtovsky, 2015; Monserrate, 2015]
- Incidence in pediatrics is similar – 25% [Leblanc, 2005]
- Headache that increases w/in 15 min of standing, improves w/in 15 min of lying down, and has ONE of the following AND also fulfills the remaining criteria:
- Neck stiffness
- Dural puncture has been performed
- Headache develops within 5 days of dural puncture
- Headache resolves either, spontaneously w/in 1 week or within 48 hours after effective treatment (usually, epidural blood patch).
[International Classification of Headache Disorders, 3rd Edition, 2013]
Help Avoid the Post LP Headache
- Post lumbar Puncture Headache is often an avoidable iatrogenic complication. [Davis, 2014]
- Patient “anxiety” does not predispose to the occurrence of post LP headache. [Khlebtovsky, 2015]
- Bed-rest/remaining supine has not been shown to decrease post LP headache. [Jacobus, 2012]
- Reinsert stylet prior to needle withdrawal
- Direct bevel perpendicular to the dura
- Use smaller needle size
- Use an Atraumatic Needle
- So this may not be up to you entirely, as it depends on what tools you have available, but…
- It has been shown that needle type influences rates of Post LP Headache [Bertolotto, 2015; Davis, 2014]
- “Cutting” needles (ex,Quincke) are most commonly used, but lead to greater risk of Post LP headache.
- Atraumatic (ex, Whitacre, Sprotte) have lower rates of Post LP Headache [Bertolotto, 2015]
- Atraumatic needles spread out the fibers of the dura, causing less trauma.
- Atraumatic needles require “more skill” as they cannot cut through skin, muscle, etc and need an introducer to do that job.
- See SpinalCSFLeak.org
Treat the Post LP Headache
- Conservative management is usually first option, because resolution often occurs within first week.
- Intravenous caffeine has been shown to be effective and safe. [Hunter, 2013]
- Epidural blood patch has been shown to be effective for resolving symptoms in children and recommended if conservative therapies are not effective. [Kokki, 2012]
Monserrate AE1, Ryman DC2, Ma S3, Xiong C4, Noble JM5, Ringman JM6, Morris JC7, Danek A8, Müller-Sarnowski F8, Clifford DB3, McDade EM9, Brooks WS10, Darby DG11, Masters CL11, Weston PS12, Farlow MR13, Graff-Radford NR14, Salloway SP15, Fagan AM3, Oliver A7, Bateman RJ3; Dominantly Inherited Alzheimer Network. Factors associated with the onset and persistence of post-lumbar puncture headache.
JAMA Neurol. 2015 Mar;72(3):325-32. PMID: 25622095
. [PubMed] [Read by QxMD]