Pediatric EM Morsels http://pedemmorsels.com Pediatric Emergency Medicine Education Fri, 23 Jan 2015 12:00:03 +0000 en-US hourly 1 http://wordpress.org/?v=4.1 Inguinal Hernia http://pedemmorsels.com/inguinal-hernia/ http://pedemmorsels.com/inguinal-hernia/#comments Fri, 23 Jan 2015 12:00:03 +0000 http://pedemmorsels.com/?p=3331 The patient with a swollen and/or painful scrotum will usually not go unnoticed. We have previously discussed testicular torsion and the...

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Inguinal hernia

The patient with a swollen and/or painful scrotum will usually not go unnoticed. We have previously discussed testicular torsion and the association of the acute scrotum and HSP.  We have also discussed the presentation of Varicoceles. Now let us look another commonly encountered cause of the acute scrotum: the Indirect Inguinal Hernia.

Inguinal Hernia – Basics

  • Most congenital abnormality requiring surgery
  • Occurs in 0.2% of live births
  • Rates are highest amongst premature infants
    • 7-10% of infants born less than 36 weeks gestastional age will have inguinal hernias. (Boocock, 1985)
  • Inguinal hernias are more common in boys.
  • They are more common on the right side.

 

Inguinal Hernia – Presentation

  • Often present within 1st year of life.
  • May present as an asymptomatic bulge in the groin or scrotum.
    • May resolve when calm and supine.
  • Can become complicated by incarceration or strangulation.
    • 7-30% of hernias
    • When incarcerated the child will become uncomfortable / irritable.

 

Inguinal Hernia – Manual Reduction

  • Strangulation of the hernia is contra-indication of manual reduction.
    • Classic teaching states that gangrenous bowel will not reduce…
      • This is not necessarily true, so just because you were successful at the reduction, doesn’t mean everything is good. (Strauch, 2002)
      • Close observation with good anticipatory guidance is required if you send the child home.
    • Signs of strangulation:
      • Severe pain
      • Bilious emesis
      • Blood in Stool
      • Signs of peritonitis
      • Redness and edema overlying the affected side of the scrotum
    • Manual Reduction Steps (suggested)
      • GIVE PAIN MEDICATIONS
        • The child will be uncomfortable as you attempt the reduction.
          • The discomfort will be counterproductive to your efforts.
          • One study showed that more than half of the kids with incarcerated hernias DID NOT receive ANY medications. (Al-Ansari, 2008)
          • Don’t be a brut.
        • Consider IV or Intranasal
      • Place in Trendelenburg position (let Gravity help you!)
      • Align the Hernia Sac
        • Instead of just pushing on the intestinal mass, which is likely swollen and slightly larger than the external inguinal ring…
        • Use gentle traction on the scrotum to help align the hernia sac with the external ring.
        • While keeping gentle traction, you can begin to attempt to decompress the contents from that bowel segment by gentle squeezing from distal to proximal.
      • Open the Internal and External Rings
        • Using the other hand, now apply pressure laterally with the index and thumb along each side of the hernia neck and inguinal canal.
        • Imagine you are trying to stretch open the rings.
      • Gently add more pressure distally and help reduce the hernia.
      • BE PATIENT!
        • This process can take several minutes.
        • Some have documented up to 40 minutes (Davies, 1990)
      • For some pictures see – NETS.ORG.AU

 

References

Al-Ansari K1, Sulowski C, Ratnapalan S. Analgesia and sedation practices for incarcerated inguinal hernias in children. Clin Pediatr (Phila). 2008 Oct;47(8):766-9. PMID: 18490664. [PubMed] [Read by QxMD]

Strauch ED1, Voigt RW, Hill JL. Gangrenous intestine in a hernia can be reduced. J Pediatr Surg. 2002 Jun;37(6):919-20. PMID: 12037764. [PubMed] [Read by QxMD]

Davies N1, Najmaldin A, Burge DM. Irreducible inguinal hernia in children below two years of age. Br J Surg. 1990 Nov;77(11):1291-2. PMID: 2101598. [PubMed] [Read by QxMD]

Boocock GR, Todd PJ. Inguinal hernias are common in preterm infants. Arch Dis Child. 1985 Jul;60(7):669-70. PMID: 4026366. [PubMed] [Read by QxMD]

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Low Risk for Intra Abdominal Trauma http://pedemmorsels.com/low-risk-intra-abdominal-trauma/ http://pedemmorsels.com/low-risk-intra-abdominal-trauma/#comments Fri, 16 Jan 2015 12:00:33 +0000 http://pedemmorsels.com/?p=3319 We have discussed pediatric trauma several times within the PedEM Morsels (Splenic Injury, Head Injury, Pneumothorax, etc), because it is often a source...

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IntraAbdominal Trauma

We have discussed pediatric trauma several times within the PedEM Morsels (Splenic Injury, Head Injury, Pneumothorax, etc), because it is often a source of trepidation, confusion and concern.  This often leads to over-reliance on ionizing radiation to help alleviate concern.  Naturally, this is not without its problems (Medical Radiation).  Is there a way to help define a group of kids who are at Low Risk for Intra Abdominal Trauma?

Pediatric Trauma- Why We Care:

  • Unintentional Injuries are leading cause of mortality in children.
  • Over the past decade, the injury death rate for children in the US decreased ~30% (in 2000, the #of Deaths = 12,441!); however, more than 9,000 children died from accidental injuries in 2009… still the #1 cause of Mortality for children.
    • 9,000 deaths > 8,760 hours/yr.
    • Every hour, ~one child DIES from an injury!
    • Every 4 seconds, a child is treated in an Emergency Department for an injury!
    • The US child injury death rate is among the worst of all high-income countries.
  • Traumatic brain injury (TBI) and thoracic trauma are the leading causes of mortality and morbidity.
  • While abdominal trauma is third most common it is the number one initially unrecognized cause of death.

Kids can be Tricky:

  • Development Matters
    • The pediatric population includes a spectrum of developmental stages, each associated with its own unique challenges.
    • Communication issues can confound evaluation and diagnosis.
    • Fear / apprehension can confound history and exam.
    • Immature children may lack the motor control to adequately protect themselves.
    • Older children may expose themselves to high risk situations by making ill-advised decisions.
  • Anatomy Matters
    • Potential for significant injuries due to less protection.
    • Relatively larger organs to body size increase risk of injury.
    • Abdominal wall musculature less protective of intra-abdominal structures.
    • Chest wall is very compliant
      • Does not dissipate applied forces, transmitting that force to the underlying structures more readily.
      • Increases work of breathing, especially with underlying injured lung.
    • Bladder is an intra-abdominal organ in young children, making it more vulnerable.
    • Kidneys are positioned more inferiorly, exposing them to injury.
    • Elastic and resilient tissues may not demonstrate external signs of trauma.
  • Physiology Matters
    • Metabolic rate is increased.
      • Even when not stressed, kids consume oxygen at >2 times adult rate.
      • Have less Function Residual Capacity (less of a reservoir of oxygen).
      • Will desaturate rapidly.
    • Cardiac output is dependent upon preload and heart rate.
      • Will increase heart rate to augment cardiac output, rather than increase contractility.
      • Conditions that adversely effect preload (tension pneumothorax, tamponade) will not be tolerated well.
    • Compensate for hypovolemia / hemorrhage very well.
      • Can maintain blood pressure even up to 30+% blood volume loss.
      • Hypotension is a late clinical indicator of hemorrhage.

Radiation is Not Without Risk:

  • Even though the evaluation of children can be challenging, this challenge should not be met with ordering a multitude of CT scans.
  • See PedEM Morsel Medical Radiation.
  • Intellectual development is adversely affected when infant brain is exposed to ionizing radiation. [Mathews, 2013].
  • CT Scans during childhood and adolescence are followed by an increase in cancer incidence (not yet determined to be a causal relationship and may, in fact, represent reverse causation). [Miglioretti, 2013]

 Low Risk for Intra-Abdominal Injury

  • Clinical prediction rule may rule out intra-abdominal injury requiring acute intervention in children with blunt torso trauma [Holmes, 2013]
    • Based on derivation cohort study without independent validation
    • 12,044 children (median age 11.1 years) with blunt torso trauma
    • 761 had intra-abdominal injury, 26.7% received acute interventions
      • Acute interventions = therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or IV fluid for ≥ 2 nights for pancreatic/gastrointestinal injuries
    • Sensitivity 97%; Specificity 42.5%
    • Prediction rule based on factors not requiring acute intervention:
      • No evidence of abdominal wall trauma or seat belt sign
      • Glasgow Coma Scale score > 13
      • No abdominal tenderness
      • No evidence of thoracic wall trauma
      • No complaints of abdominal pain
      • No decreased breath sounds
      • No vomiting
  • The abdominal exam is useful!
    • Risk of intra-abdominal injury increased as degree of abdominal findings increased.
    • Either abdominal tenderness OR abdominal pain in isolation are associated with non-negligible risk and warrants evaluation.
      • Isolated abdominal tenderness or pain = 8% had intra-abdominal injury
      • Isolated abdominal pain = 3 % had intra-abdominal injury.
    • GCS affects sensitivity of abdominal tenderness.
      • GCS 15 – abdominal tenderness sensitivity = 79%
      • GCS 14 – abdominal tenderness sensitivity = 57%
      • GCS 13 – abdominal tenderness sensitivity = 37%
    • Seat Belt Sign matters
      • Seat Belt Sign is associated with increased risk for intra-abdominal injury, particularly hollow viscus or mesenteric injury.
      • Seat Belt Sign without pain or tenderness had lower risk for injury, but still warrant evaluation.
    • Evaluation for possible Intra-Abdominal Injury does not necessarily equal CT Scan.
      • Further risk stratification can be done via:
        • Serial Exams and Observation (my personal preference… in addition to U/S)
        • Bedside Ultrasound
        • Laboratory studies
          • AST > 200 U/L
          • ALT > 125 U/L
          • Hematuria (>5 RBCs / HPF)
          • Initial Hematocrit < 30%

References

Adelgais KM1, Kuppermann N2, Kooistra J3, Garcia M4, Monroe DJ5, Mahajan P6, Menaker J7, Ehrlich P8, Atabaki S9, Page K10, Kwok M11, Holmes JF12; Intra-Abdominal Injury Study Group of the Pediatric Emergency Care Applied Research Network (PECARN). Accuracy of the abdominal examination for identifying children with blunt intra-abdominal injuries. J Pediatr. 2014 Dec;165(6):1230-1235. PMID: 25266346. [PubMed] [Read by QxMD]

Borgialli DA1, Ellison AM, Ehrlich P, Bonsu B, Menaker J, Wisner DH, Atabaki S, Olsen CS, Sokolove PE, Lillis K, Kuppermann N, Holmes JF; Pediatric Emergency Care Applied Research Network (PECARN). Association between the seat belt sign and intra-abdominal injuries in children with blunt torso trauma in motor vehicle collisions. Acad Emerg Med. 2014 Nov;21(11):1240-8. PMID: 25377401. [PubMed] [Read by QxMD]

Holmes JF1, Lillis K, Monroe D, Borgialli D, Kerrey BT, Mahajan P, Adelgais K, Ellison AM, Yen K, Atabaki S, Menaker J, Bonsu B, Quayle KS, Garcia M, Rogers A, Blumberg S, Lee L, Tunik M, Kooistra J, Kwok M, Cook LJ, Dean JM, Sokolove PE, Wisner DH, Ehrlich P, Cooper A, Dayan PS, Wootton-Gorges S, Kuppermann N; Pediatric Emergency Care Applied Research Network (PECARN). Identifying children at very low risk of clinically important blunt abdominal injuries. Ann Emerg Med. 2013 Aug;62(2):107-116. PMID: 23375510. [PubMed] [Read by QxMD]

Nishijima DK1, Yang Z, Clark JA, Kuppermann N, Holmes JF, Melnikow J. A cost-effectiveness analysis comparing a clinical decision rule versus usual care to risk stratify children for intraabdominal injury after blunt torso trauma. Acad Emerg Med. 2013 Nov;20(11):1131-8. PMID: 24238315. [PubMed] [Read by QxMD]

Miglioretti DL1, Johnson E, Williams A, Greenlee RT, Weinmann S, Solberg LI, Feigelson HS, Roblin D, Flynn MJ, Vanneman N, Smith-Bindman R. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr. 2013 Aug 1;167(8):700-7. PMID: 23754213. [PubMed] [Read by QxMD]

Mathews JD1, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, Giles GG, Wallace AB, Anderson PR, Guiver TA, McGale P, Cain TM, Dowty JG, Bickerstaffe AC, Darby SC. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ. 2013 May 21;346:f2360. PMID: 23694687. [PubMed] [Read by QxMD]

Holmes JF1, Mao A, Awasthi S, McGahan JP, Wisner DH, Kuppermann N. Validation of a prediction rule for the identification of children with intra-abdominal injuries after blunt torso trauma. Ann Emerg Med. 2009 Oct;54(4):528-33. PMID: 19250706. [PubMed] [Read by QxMD]

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Spleen Injury http://pedemmorsels.com/splenic-injury/ http://pedemmorsels.com/splenic-injury/#comments Fri, 09 Jan 2015 12:00:09 +0000 http://pedemmorsels.com/?p=3287 Recently we discussed abusive occult abdominal injuries and how a high index of suspicion is often required as the physical exam...

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Splenic Rupture

Recently we discussed abusive occult abdominal injuries and how a high index of suspicion is often required as the physical exam can be misleading.  The same is true with respect to accidental injuries, which are the leading cause of morbidity and mortality in children.  We have discussed head injury, pulmonary contusion, aortic trauma, and traumatic pneumothorax.  Now, let’s move into the abdomen and consider Splenic Injury!

 

Splenic Injury – Basics

  • The spleen is the most commonly injured abdominal organ.
    • Up to 45% of patients with blunt abdominal trauma will have splenic injury. (Costa, 2010)
  • More commonly injured in school-aged children and adolescents (when dangerous activities really start).
  • MVC is the most common cause of spleen injury.
    • Highest mortality seen when associated with MVC and concurrent head injury.
    • Mortality is as high as 12% when multi-trauma.

 

Splenic Injury – Presentation

  • A high index of suspicion should be maintained. (Hildebrand, 2014)
    • The pediatric patient’s compliant chest wall does not offer as much protection as the adult’s ribcage.
    • The pediatric patient can have significant injury with minimal external signs of trauma.
  • Consider Splenic Injury in:
    • pt with trauma to left thorax or abdomen
    • pt with hemodynamic instability (remembering that pediatric patients become hypotensive very late!!)
    • pt complaining of left shoulder pain after abdominal trauma
    • pt with noted rib fractures (it takes a lot of force to fracture those compliant pediatric ribs)
    • pt with multi-trauma
  • Unfortunately, a contained rupture may have few initial symptoms.
  • Delayed presentations are not uncommon.

 

Splenic Injury – Grading Systems

  • There are two commonly used grading systems for splenic injuries
  • Neither is perfect and both require astute clinical judgement.
  • American Assoication for Surgery of Trauma (AAST) Organ Injury Scale (Moore, 1989)
    • I = Minor subcapsular hematoma, tear < 1cm
    • II = Subcapsular hematoma 10-50% of surface, intraparenchymal hematoma < 5cm, capsular tear 1-3 cm
    • III = Subcapsular hematoma >50%, intraparenchymal hematoma > 5cm, laceration >3cm or involved trabecular vessel
    • IV = laceration involving segmental or hilar vessels with major devascularlization
    • V = Shattered spleen or hilar vascular injury that devascularizes the spleen
  • Baltimore CT Grading System (Marmery, 2007)
    • 1 = Subcapsular hematoma < 1 cm thick, Laceration < 1 cm deep, parenchymal hematoma <1 cm in diameter.
    • 2 = Subcapsular hematoma 1-3 cm thick, laceration 1-3 cm deep, parenchymal hematoma 1-3 cm in diameter.
    • 3 = Capsular disruption, Subcapsular hematoma > 3 cm thick, laceration > 3 cm deep, parenchymal hematoma > 3cm in diameter.
    • 4a = Active intraparenchymal and subcapsular splenic bleeding, vascular injury (pseudoaneurysm or ateriorvenous fistula), shattered spleen
    • 4b = Active intraperitoneal bleeding
  • There is evidence that the “Baltimore CT Grading System” is better at predicting need for arteriography and surgery. [Marmery, 2007]
  • The “Baltimore CT Grading System” has been recently advocated as helping with clinical decisions. [Olthof, 2012]

 

Splenic Injury: Management

  • Non-operative Management
    • Preferred approach if possible.
    • No controversy over the lower graded injuries.
    • Questions surround the higher graded injuries, but based on clinical assessment, non-op management may be feasible.
    • If hemodynamically stable at 4-6 hours post injury, then splenectomy is rarely required.
  • AngioEmbolization
    • Consider for patients with:
      • > Grade III
      • Presence of contrast blush / extravasation
      • Moderate hemoperitoneum
      • Evidence of ongoing bleeding (i.e., decreasing Hgb levels)
    • Use appears to improve organ salvage rates.
  • Ex-Lap Salvage Techniques
    • In hemodynamically stable pt, undergoing laparotomy for other injuries.
    • Can apply topical hemostatic agents (ex, fibrin glue).
  • Splenectomy
    • Isolated splenic injury rarely requires splenectomy, but…
    • Sometimes, it just has to come out.

 

Post-Splenectomy Concerns!

  • Patients status post splenectomy are at risk for sepsis.
    • Rarely occurs in patients who keep their spleen.
    • Mortality from post-splenectomy sepsis ranges from 38% – 69%
    • S. pneumonia is most common agent.
  • Vaccinations, will have attenuated effect, but are recommended and need to be kept up to date!
    • Pneumococcal Vaccine
    • HiB Vaccine
    • Meningococcal Vaccine
    • Annual Influenza Vaccine
  • Prophlyactic antibiotics
    • Oral penicillin is recommended for high risk patients (ex, kids < 5 years of age)

 

References

Hildebrand DR1, Ben-Sassi A, Ross NP, Macvicar R, Frizelle FA, Watson AJ. Modern management of splenic trauma. BMJ. 2014 Apr 2;348:g1864. PMID: 24696170. [PubMed] [Read by QxMD]
Olthof DC1, van der Vlies CH, Scheerder MJ, de Haan RJ, Beenen LF, Goslings JC, van Delden OM. Reliability of injury grading systems for patients with blunt splenic trauma. Injury. 2014 Jan;45(1):146-50. PMID: 23000055. [PubMed] [Read by QxMD]

Costa G1, Tierno SM, Tomassini F, Venturini L, Frezza B, Cancrini G, Stella F. The epidemiology and clinical evaluation of abdominal trauma. An analysis of a multidisciplinary trauma registry. Ann Ital Chir. 2010 Mar-Apr;81(2):95-102. PMID: 20726387. [PubMed] [Read by QxMD]

Marmery H1, Shanmuganathan K, Alexander MT, Mirvis SE. Optimization of selection for nonoperative management of blunt splenic injury: comparison of MDCT grading systems. AJR Am J Roentgenol. 2007 Dec;189(6):1421-7. PMID: 18029880. [PubMed] [Read by QxMD]

Moore EE1, Cogbill TH, Jurkovich GJ, Shackford SR, Malangoni MA, Champion HR. Organ injury scaling: spleen and liver (1994 revision). J Trauma. 1995 Mar;38(3):323-4. PMID: 7897707. [PubMed] [Read by QxMD]
Moore EE1, Shackford SR, Pachter HL, McAninch JW, Browner BD, Champion HR, Flint LM, Gennarelli TA, Malangoni MA, Ramenofsky ML, et al. Organ injury scaling: spleen, liver, and kidney. J Trauma. 1989 Dec;29(12):1664-6. PMID: 2593197. [PubMed] [Read by QxMD]

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Baclofen Pump http://pedemmorsels.com/baclofen-pump/ http://pedemmorsels.com/baclofen-pump/#comments Fri, 02 Jan 2015 12:00:02 +0000 http://pedemmorsels.com/?p=3266   Medical technology continues to advance with the goal of improving patient care, but as the march toward the future seems...

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Baclofen Pump

 

Medical technology continues to advance with the goal of improving patient care, but as the march toward the future seems to occur more rapidly each year, it is our challenge to stay abreast of the good and the, potentially, bad for each advancement.  Let us take this opportunity to look at Baclofen Pumps.

 

Baclofen

  • What is it?

    • Baclofen is a derivative of gamma-aminobutyric acid (GABA), the inhibitory neurotransmitter.
    • It is a agonist for the GABA B receptors at the spinal and supra spinal sites.
    • Has anti-spasticity effects.
  • Why it’s used in kids?

    • Most commonly used for treating spasticity related spinal cord disease:
      • Cerebral Palsy
      • Spinal Cord Injury
      • Generalized Dystonia
      • Mutliple Sclerosis
    • Some use for intractable hiccups
  • How it’s Given

    • Oral or IV
    • Topical creams
    • Intrathecal via Implantable Device

 

Baclofen Toxicity

  • Baclofen toxicity has been reported after intrathecal and oral administration (both accidental and intentional).
  • Baclofen crosses the blood-brain barrier.
  • Clinical findings:
    • Muscular hypotonia
    • Areflexia
    • Somnolence
    • Respiratory Depression
    • Bradycardia
    • Hypotension
    • Temperature instability
    • Coma
    • May mimic brain death (Ostermann, 2000)
  • Symptoms can occur rapidly.
  • Diagnosis is clinical, as measuring plasma levels is not always reliable.
  • Treatment

    • Primarily treatment is supportive (IV Fluids, Inotropes, Airway Support)
    • Limit the Baclofen exposure (if a implantable pump is being used, drain the reservoir).
    • Physostigmine
      • There are case reports of it being effective and some advocate for its consideration. (Yeh, 2004)
      • It may cause bradycardia and increased airway secretions.

 

Baclofen Withdrawal

  • Acute withdrawal of Baclofen can lead to severe symptoms and death if not recognized and treated.
  • Clinical Findings: (Yeh, 2004)
    • Itching
    • Dysphoria
    • Rebound Spasticity
    • Audio and Visual Hallucinations
    • Paranoia
    • Seizures
    • Rhabdomyolysis
    • Death
  • Symptoms may start to develop during the course of treating Baclofen Toxicity. (Darbari, 2005)
  • Treatment

    • Supportive Care (ABCs as always)
    • Oral or Enteral Baclofen (Yeh, 2004)
      • Should be initiated at the earliest signs of withdrawal.
      • Be looking for generalized itching or increased spasticity.
    • High dose Benzodiazepines

 

Baclofen Pump

  • Intrathecal delivery allows for a much lower dose (100-1000 fold).
  • Determination of dosage is complex.
  • Mechanics

    • Baclofen Reservoir
      • The pump has a reservoir that is filled with baclofen periodically.
      • The access point for the pump’s reservoir can also be used to extract the medication also.
    • Catheter Access Port
      • Adjacent to the connection of the catheter.
      • The Catheter Access Port can be used to extract remaining baclofen in catheter and CSF if needed.
    • Pump Motor
      • Programmable via bedside computer.
      • Automatically turns off when reservoir is empty.
  • Toxicity may occur as a result of device error or human error.
  • Suggested Approach to Toxicity related to Baclofen Pump. (Yeh, 2004)
    • ABCs and Supportive Care
    • Obtain the device-associated computer to turn off device and assess it (this may take some time to get, so move on to next steps).
    • Obtain the device-specific template guide that, when placed over the device, helps to locate the access sites.
    • Empty the Reservoir to stop the motor (so no more of the Baclofen in the catheter will enter the thecal sac).
    • Withdraw fluid / CSF from the Catheter Access Port (to extract any Baclofen that is still in the catheter or adjacent to it).
    • Consider Physostigmine if not contraindicated.
    • Admit to the ICU.

 

References

Ghosh D1, Mainali G, Khera J, Luciano M. Complications of intrathecal baclofen pumps in children: experience from a tertiary care center. Pediatr Neurosurg. 2013;49(3):138-44. PMID: 24577095. [PubMed] [Read by QxMD]

Caron E1, Morgan R, Wheless JW. An unusual cause of flaccid paralysis and coma: baclofen overdose. J Child Neurol. 2014 Apr;29(4):555-9. PMID: 23481445. [PubMed] [Read by QxMD]

Dickey MP1, Rice M, Kinnett DG, Lambert R, Donauer S, Gerber MA, Staat MA. Infectious complications of intrathecal baclofen pump devices in a pediatric population. Pediatr Infect Dis J. 2013 Jul;32(7):715-22. PMID: 23429557. [PubMed] [Read by QxMD]

Borowski A1, Littleton AG, Borkhuu B, Presedo A, Shah S, Dabney KW, Lyons S, McMannus M, Miller F. Complications of intrathecal baclofen pump therapy in pediatric patients. J Pediatr Orthop. 2010 Jan-Feb;30(1):76-81. PMID: 20032747. [PubMed] [Read by QxMD]

Vender JR1, Hester S, Waller JL, Rekito A, Lee MR. Identification and management of intrathecal baclofen pump complications: a comparison of pediatric and adult patients. J Neurosurg. 2006 Jan;104(1 Suppl):9-15. PMID: 16509474. [PubMed] [Read by QxMD]

Darbari FP1, Melvin JJ, Piatt JH Jr, Adirim TA, Kothare SV. Intrathecal baclofen overdose followed by withdrawal: clinical and EEG features. Pediatr Neurol. 2005 Nov;33(5):373-7. PMID: 16243227. [PubMed] [Read by QxMD]

Yeh RN1, Nypaver MM, Deegan TJ, Ayyangar R. Baclofen toxicity in an 8-year-old with an intrathecal baclofen pump. J Emerg Med. 2004 Feb;26(2):163-7. PMID: 14980337. [PubMed] [Read by QxMD]

Ostermann ME1, Young B, Sibbald WJ, Nicolle MW. Coma mimicking brain death following baclofen overdose. Intensive Care Med. 2000 Aug;26(8):1144-6. PMID: 11030173. [PubMed] [Read by QxMD]

Müller-Schwefe G1, Penn RD. Physostigmine in the treatment of intrathecal baclofen overdose. Report of three cases. J Neurosurg. 1989 Aug;71(2):273-5. PMID: 2746350. [PubMed] [Read by QxMD]

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Dexamethasone for Asthma http://pedemmorsels.com/dexamethasone-asthma/ http://pedemmorsels.com/dexamethasone-asthma/#comments Fri, 26 Dec 2014 17:41:53 +0000 http://pedemmorsels.com/?p=3249 Reactive airway disease is a prevalent problem and, therefore, a common topic for the Morsels.  We have discussed my preference for...

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Dexamethasone

Reactive airway disease is a prevalent problem and, therefore, a common topic for the Morsels.  We have discussed my preference for MDIs over Nebs as well as the utility of Magnesium.  In addition, we have covered mechanical ventilation for asthma and how Delayed Sequence Intubation may be a useful tactic.  One aspect that we have not yet covered, though, is the utility of Dexamethasone for the treatment of Asthma.

 

Oral Steroids Are Useful

  • Asthma is a chronic inflammatory disorder of the airways.
  • Corticosteroids reduce airway hyperresponsiveness, inhibit inflammatory cell migration and activation, and block late-phase reaction to allergens. (Busse, 2007)
    • Inhaled Steroids improve control of asthma and are safe and well tolerated by children.
    • Inhaled Steroids do not improve acute exacerbations.
  • Moderate or Severe Exacerbations require SYSTEMIC Steroids. (Busse, 2007)
    • High-dose inhaled corticosteroids are not effective in severe exacerbations. (Henedeles, 2003)
      • There is some evidence that children with good compliance to inhaled-corticosteroid regimens may be able to increase dose at onset of exacerbation to prevent need for systemic steroids. (Volovitz, 2008)
      • I’d say that these are generally not the patients presenting to your ED.
      • Use of inhaled-corticosteroids in the ED are generally aimed at improving technique, reinforcing eduction, and potential initiating their use.
    • Systemic steroids are recommended for patients not responding to initial short-acting Beta-agonists.

 

Taking Oral Steroids Can Be Challenging

Aside from the known side effects of steroids, convincing a child to take oral steroids can be difficult.

  • Giving patients’ families prescriptions to get filled adds one more, potentially difficult, step to their management of the patient.
    • Some will have financial limitations.
    • Some will have transportation limitations.
    • Some will have “memory limitations” (Just forgot to get them).
  • Even if the prednisone is obtained, the task of taking it is not easy.
    • Prednisone is generally not considered to be very tasty.
    • Short bursts of steroids are typically for 3-5 days, which doesn’t seem like that long of a time, until you are the parent trying “convince” him/her to take the medicine.

 

Dexamethasone May Offer a Better Option

  • Dexamethasone Pharmacodynamics
    • Potency – Dexamethasone is 5-6 times more potent than prednisone.
    • Half-life – Dexamethasone has 4-5 longer 1/2 life than prednisone.
  • Several small studies have investigated the utility of oral dexamethasone for acute asthma exacerbations.
    • Each has it’s own limitations (as so many studies do).
    • Meta-analyses have attempted to gather together the higher quality studies (and, naturally, have their own limitations).
  • There does appear to be a consistent trend amongst these studies:
    • Oral Dexamethasone has similar efficacy, but has less side-effects (ex, vomiting) and improved compliance compared to prednisone. (Qureshi, 2001)
    • A SINGLE DOSE or TWO-DOSES of Oral Dexamethasone is NOT inferior to 5-day regimen of Prednisone. (Keeney, 2014) (Schwarz, 2014)
    • The use of oral dexamethasone is not associated with more unscheduled medical evaluations when compared to prednisone.
  • Oral Dexamethasone is preferred by patients and families.
    • Families prefer the shorter duration of therapy (1 or 2 doses). (Williams, 2013)
    • Dexamethasone is more palatable compared to prednisone and is preferred by pediatric patients. (Hames, 2008)
  • Decision analysis models have shown that 2 days of oral dexamethasone leads to cost savings (less return visits, admissions, etc) compared to 5 days of prednisone. (Lintzenich, 2012)

 

So the next time you are ordering oral steroids for your patients with acute asthma exacerbations, consider utilizing either a single dose or two-doses of dexamethasone as a way to improve compliance and lead to beneficial results.

 

References

Keeney GE1, Gray MP, Morrison AK, Levas MN, Kessler EA, Hill GD, Gorelick MH, Jackson JL. Dexamethasone for acute asthma exacerbations in children: a meta-analysis. Pediatrics. 2014 Mar;133(3):493-9. PMID: 24515516. [PubMed] [Read by QxMD]

Williams KW1, Andrews AL, Heine D, Russell WS, Titus MO. Parental preference for short- versus long-course corticosteroid therapy in children with asthma presenting to the pediatric emergency department. Clin Pediatr (Phila). 2013 Jan;52(1):30-4. PMID: 23034948. [PubMed] [Read by QxMD]

Andrews AL1, Wong KA, Heine D, Scott Russell W. A cost-effectiveness analysis of dexamethasone versus prednisone in pediatric acute asthma exacerbations. Acad Emerg Med. 2012 Aug;19(8):943-8. PMID: 22849379. [PubMed] [Read by QxMD]

Greenberg RA1, Kerby G, Roosevelt GE. A comparison of oral dexamethasone with oral prednisone in pediatric asthma exacerbations treated in the emergency department. Clin Pediatr (Phila). 2008 Oct;47(8):817-23. PMID: 18467673. [PubMed] [Read by QxMD]

Hames H1, Seabrook JA, Matsui D, Rieder MJ, Joubert GI. A palatability study of a flavored dexamethasone preparation versus prednisolone liquid in children. Can J Clin Pharmacol. 2008 Winter;15(1):e95-8. PMID: 18245869. [PubMed] [Read by QxMD]

Volovitz B1, Bilavsky E, Nussinovitch M. Effectiveness of high repeated doses of inhaled budesonide or fluticasone in controlling acute asthma exacerbations in young children. J Asthma. 2008 Sep;45(7):561-7. PMID: 18773327. [PubMed] [Read by QxMD]

National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007 Nov;120(5 Suppl):S94-138. PMID: 17983880. [PubMed] [Read by QxMD]

Hendeles L1, Sherman J. Are inhaled corticosteroids effective for acute exacerbations of asthma in children? J Pediatr. 2003 Feb;142(2 Suppl):S26-32; discussion S32-3. PMID: 12584517. [PubMed] [Read by QxMD]

Qureshi F1, Zaritsky A, Poirier MP. Comparative efficacy of oral dexamethasone versus oral prednisone in acute pediatric asthma. J Pediatr. 2001 Jul;139(1):20-6. PMID: 11445789. [PubMed] [Read by QxMD]

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Lactate Level in Kids http://pedemmorsels.com/lactate-level-kids/ http://pedemmorsels.com/lactate-level-kids/#comments Fri, 19 Dec 2014 20:54:27 +0000 http://pedemmorsels.com/?p=3229 Patients’ families often present to us requesting “bloodwork” to make sure that the child is not “sick” or to tell them...

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Lactate

Patients’ families often present to us requesting “bloodwork” to make sure that the child is not “sick” or to tell them “what’s wrong.”  While we all know that no lab can be used to proclaim complete certainty of a patient’s health or to make a definitive diagnosis on its own, often we perpetuate the myth by ordering labs that do not necessarily direct our actions.  By now, most of you know of my disdain for the ubiquitous WBC count (The Last Bastion of the Intellectually Destitute – Amal Mattu), but there is another often ordered test that may also fall into that category — the Lactate Level.

The Lactate Level has grown in popularity over the past decade, particularly in the Adult EDs.  Certainly, there is literature that supports its utility with respect to evaluation of SEPSIS and trauma, but this often becomes extrapolated to all patients who “may be sick” as a means to find the covertly ill.  This  approach (often in a “shotgun” fashion) has steadily crept into the Pediatric EDs as well.  What is the known utility of Lactate Level in children? [Thank you @ErnestoAlarco12 for inspiring the question].

 

Lactate Level – Basic BioChem

  • Just in case you don’t recall BioChem class as well as you used to…
  • During Glycolysis glucose is converted into Pyruvate.
    • Through AEROBIC metabolism, pyruvate is used to generate 2 Acetyl-CoA and eventually many ATPs, H2O, and CO2 (remember the Krebs cycle?).
    • When there is not enough Oxygen around (ANAEROBIC metabolism), then pyruvate is converted into Lactate.
    • Lactate can be converted back to pyruvate once the oxygen deficit has been corrected.
    • Well that was a fun walk down memory lane.
  • With this in mind, elevated lactate levels would potentially reflect tissue oxygen deficit.
  • Under normal conditions, lactate is rapidly cleared by the liver, with some assistance from the kidneys. (Anderson, 2013)
  • There is no standardized levels:
    • Most studies use cutoff values of 2.0 to 2.5 mmol/L.
    • Many define “High” as a Lactate level > 4.0 mmol/L. (Anderson, 2013)

 

Lactate Level – Some Causes of Lactate Elevation

Most often elevated Lactate Levels conjure thoughts of tissue hypoperfusion with diminished access to oxygen (SHOCK), but there are others causes to consider. (Anderson, 2013)

  • Global ischemia (SHOCK)
  • Regional ischemia (ex, mesenteric ischemia, burns, trauma, compartment syndrome)
  • High Metabolic States (ex, seizures, heavy exercise, increased work of breathing)
  • Drugs (ex, Metformin, epinephrine, propofol, acetominophen, beta-2-agonists)
  • Toxins (ex, Cocaine, Cyanide, Carbon monoxide, alcohols)
  • Malignancies
  • Liver Disease (can’t clear the lactate)
  • Diabetic Ketoacidosis
  • Thiamine Deficiency (w/o thiamine, anaerobic metabolism predominates)
  • Inborn Errors of Metabolism and Mitochondrial Diseases

 

Lactate Level – Elevation in Kids

  • In the PICU:
    • Studies of SEPSIS have shown increased mortality in the setting of elevated lactate levels. (Jat, 2011)
    • Monitoring serial lactate levels in patients following surgery for congenital heart disease can help discriminate patients at high risk. (Schumacher, 2014; Agrawal, 2012)
    • Poor lactate clearance (< 30% at 6 hours) has been associated with increased risk of mortality. (Munde, 2012)
    • High lactate level upon admission to the PICU is associated with in-hospital mortality. (Bai, 2014)
  • In the ED:
    • High lactate levels can be useful to help “rule-in” severe bacterial infection in children in the ED. (Vorwek, 2011)
    • High lactate levels identify a population at higher risk for severe outcomes amongst the kids with SIRS in the Peds ED. (Scott, 2012)
    • After Return of Spontaneous Circulation following a resuscitation, higher lactate levels are associated with higher likelihood of death, although don’t predict outcomes. (Topjian, 2013)
    • Elevated lactate levels obtained in pediatric trauma patients during prehospital transport are associated with increased need for critical care. (Shah, 2013)

 

Lactate Level – Did it Help You?

  • Thus far, we see that, like in adults, an elevated lactate can help identify those patients who are potentially sicker than others, although not perfectly.
  • One issue is that, often, an astute clinician would generate a similar assessment of clinical severity. (Scott, 2012)
  • Another issue is that, when obtained in the “shotgun” approach of obtaining labs, often the confounders (see above) are not taken into account.
  • It is only helpful if it alerts you to severe illness presenting subtly or helps direct your resuscitation efforts… which, again, require the astute clinician to determine.

 

References

Munde A1, Kumar N, Beri RS, Puliyel JM. Lactate clearance as a marker of mortality in pediatric intensive care unit. Indian Pediatr. 2014 Jul;51(7):565-7. PMID: 25031136. [PubMed] [Read by QxMD]

Bai Z, Zhu X, Li M, Hua J, Li Y, Pan J, Wang J, Li Y1. Effectiveness of predicting in-hospital mortality in critically ill children by assessing blood lactate levels at admission. BMC Pediatr. 2014 Mar 28;14:83. PMID: 24673817. [PubMed] [Read by QxMD]

Schumacher KR1, Reichel RA2, Vlasic JR2, Yu S2, Donohue J2, Gajarski RJ2, Charpie JR2. Rate of increase in serum lactate level risk-stratifies infants after surgery for congenital heart disease. J Thorac Cardiovasc Surg. 2014 Aug;148(2):589-95. PMID: 24138790. [PubMed] [Read by QxMD]

Shah A1, Guyette F, Suffoletto B, Schultz B, Quintero J, Predis E, King C. Diagnostic accuracy of a single point-of-care prehospital serum lactate for predicting outcomes in pediatric trauma patients. Pediatr Emerg Care. 2013 Jun;29(6):715-9. PMID: 23714761. [PubMed] [Read by QxMD]

Topjian AA1, Clark AE, Casper TC, Berger JT, Schleien CL, Dean JM, Moler FW; Pediatric Emergency Care Applied Research Network. Early lactate elevations following resuscitation from pediatric cardiac arrest are associated with increased mortality*. Pediatr Crit Care Med. 2013 Oct;14(8):e380-7. PMID: 23925146. [PubMed] [Read by QxMD]

Andersen LW1, Mackenhauer J, Roberts JC, Berg KM, Cocchi MN, Donnino MW. Etiology and therapeutic approach to elevated lactate levels. Mayo Clin Proc. 2013 Oct;88(10):1127-40. PMID: 24079682. [PubMed] [Read by QxMD]

Agrawal A1, Agrawal N, Das J, Varma A. Point of care serum lactate levels as a prognostic marker of outcome in complex pediatric cardiac surgery patients: Can we utilize it? Indian J Crit Care Med. 2012 Oct;16(4):193-7. PMID: 23559725. [PubMed] [Read by QxMD]

Vorwerk C1, Manias K, Davies F, Coats TJ. Prediction of severe bacterial infection in children with an emergency department diagnosis of infection. Emerg Med J. 2011 Nov;28(11):948-51. PMID: 20971726. [PubMed] [Read by QxMD]

Jat KR1, Jhamb U, Gupta VK. Serum lactate levels as the predictor of outcome in pediatric septic shock. Indian J Crit Care Med. 2011 Apr;15(2):102-7. PMID: 21814374. [PubMed] [Read by QxMD]

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Rectal Prolapse http://pedemmorsels.com/rectal-prolapse/ http://pedemmorsels.com/rectal-prolapse/#comments Fri, 12 Dec 2014 12:00:01 +0000 http://pedemmorsels.com/?p=3211   Parental concerns, appropriately, drive a lot of the traffic to our Emergency Departments.  Managing concerns and expectations is part of...

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Rectal Prolapse

 

Parental concerns, appropriately, drive a lot of the traffic to our Emergency Departments.  Managing concerns and expectations is part of the art of what we do.  When a child develops Rectal Prolapse, there are often a lot of concerns, but it is important to keep some basic issues in mind.

 

Rectal Prolapse: Basics

  • Generally is a benign condition.
  • Often get sent to surgeons and GI specialists, but rarely require more than conservative management.
    • ~90% of kids 9 months to 3 years will not need additional therapy.
  • Most common under age 4 years!  Highest Incidence is <1 year of age.
    • The prognosis is more ominous in kids who develop it after age 4 years.
  • Mechanically, it is an intussusception of the rectum.
  • Classification of Prolapse: (Siafakas, 1999)
    • Mucosal Prolapse – Mucosa only; Generally < 2cm; Has radial folds
    • Complete Prolapse – Full Thickness; > 2cm, Has various Degrees/Severities based on length and whether the mucocutaneous junction is involved; Has circular folds
      • Third Degree actually is internal and does not pass through the anus.

 

Rectal Prolapse: Why it Happens

  • Anatomy Matter

    • More vertical course of the rectum along the sacrum.
    • Low position of the rectum and increased mobility of the sigmoid colon.
    • Lack of support by the levator ani muscle.
  •  Associated Conditions (Siafakas, 1999)

    • Increased intra-abdominal pressure
      • Chronic straining (constipation)
      • Attempts at toilet training at a developmentally inappropriate time.
      • Protracted coughing spells (Pertussis?)
      • Excessive vomiting
    • Diarrheal Illness
      • Acute or Chronic
      • Infectious diarrhea (ex, shigella, C.Diff)
      • Malaborption (ex, celiac, pancreatic insufficiency)
        • Cystic Fibrosis accounts for ~11% of rectal prolapse in the Western World, likely from multiple mechanisms.
        • Rectal Prolapse may be the presenting sign of Cystic Fibrosis in up to 33% of patients before other symptoms!
    • Parasitic Disease (ex, whipworms)
    • Neoplastic Disease (ex, polyps)
    • Malnutrition
      • Worldwide, likely most common condition associated with rectal prolapse.
      • Due to loss of fat leading to less perirectal support.
    • Neurologic Disorders (ex, Myelomeningoceles)
    • Misc: Congenital Hypothyroidism, Ehlers-Danlos Syndrome, Hirschsrpung’s.

 

Rectal Prolapse: Management

  • Most often the child with rectal prolapse will spontaneously reduce prior to your exam.
  • If it is still present, consider a few entities prior to simply reducing it. (Siafakas, 1999)
    • Ileocecal Intussusception
      • Can actually protrude from the rectum.
      • Distinguished from rectal prolapse by:
        • Child appears clinically ill and
        • Examiner’s finger can pass between prolapsed tissue and the anal sphincter.
    • Rectal Polyp that has Prolapsed
      • May appear during defecation and then reduce.
      • Does not involve the entire anal circumference.
  • Reduce it!
    • If it still is prolapsed, reduce it with steady pressure .
    • If it has been prolapsed for awhile, there may be swelling.
    • Firm, steady pressure with fingertips may be required for several minutes.
    • Many will talk about applying sugar to help lessen the edema, but I have not found any definitive literature on this.
  • Ask yourself why it happened!
    • See the above issues and consider whether any are the cause.
    • Unexplained rectal prolapse deserves follow-up for possible cystic fibrosis testing.

 

References

Flum AS1, Golladay ES, Teitelbaum DH. Recurrent rectal prolapse following primary surgical treatment. Pediatr Surg Int. 2010 Apr;26(4):427-31. PMID: 20238206. [PubMed] [Read by QxMD]

Siafakas C1, Vottler TP, Andersen JM. Rectal prolapse in pediatrics. Clin Pediatr (Phila). 1999 Feb;38(2):63-72. PMID: 10047938. [PubMed] [Read by QxMD]

Zempsky WT1, Rosenstein BJ. The cause of rectal prolapse in children. Am J Dis Child. 1988 Mar;142(3):338-9. PMID: 3344723. [PubMed] [Read by QxMD]

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