Pediatric EM Morsels Pediatric Emergency Medicine Education Fri, 31 Jul 2015 11:00:23 +0000 en-US hourly 1 Shoulder Dislocation Fri, 31 Jul 2015 11:00:23 +0000 Kids always seem to test gravity… and continually find that it works.  While gravity certainly has its advantages, it also tends...

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Shoulder Dislocation

Kids always seem to test gravity… and continually find that it works.  While gravity certainly has its advantages, it also tends to lead to a fair amount of injuries for our pediatric patients.  We have covered numerous orthopaedic topics previous in the PedEM Morsels (ex, osteomyelitis, patellar dislocation, SCFE, supracondylar fractures, nursemaid’s elbow), but let’s take a moment to look at yet another: Shoulder Dislocation.


Shoulder Dislocations in Kids

  • Shoulder dislocations are less common in children than adults.
  • ~20% of all glenohumeral dislocations occur in patients <20 years of age.
  • <2% occur in kids younger <10 years of age. [Zacchilli, 2010]


Shoulder Anatomy

  • The proximal humerus has 3 primary ossifications centers:
    • Humeral Head
    • Great Tuberosity
    • Lesser Tuberosity
  • Ossification centers close between 5-7 years of age.
  • The proximal humeral physis then fuses to humeral shaft between 14-17 years.
  • Inherently unstable joint:
    • The glenoid fossa is shallow.
    • Stability of the joint is most dependent upon the ligamentous, muscular, and joint capsule structures.
  • The proximal humeral physis is extra-articular in skeletally immature kids.
  • Physeal fractures are possible after shoulder dislocation in the skeletally immature. [Xinning, 2013]
  • The shoulder capsule, however, is more elastic in the younger children, and may help prevent recurrent dislocations in the future.


Shoulder Dislocation Presentation

  • Traumatic shoulder dislocations often have obvious deformity.
    • Arm is typically ADDucted and internally rotated (if anteroinferior dislocation).
    • Acromion will appear prominent.
    • Palpable cavity beneath the acromion, where the humeral once was sitting.
  • May also occur without an associated trauma.
    • Often due to prior dislocation related joint instability.
    • May be more subtle and the patient may describe an apprehension that it will dislocate.


Shoulder Dislocation Evaluation

  • Axillary nerve is the most commonly injured nerve during shoulder dislocations.
    • As always, assessment of neurologic status is imperative.
  • Do you need prereduction films?
    • If there is a question as to whether it is dislocated, then yes.
    • If there was an associated high-energy mechanism, then yes.
    • If clinically apparent and non-concerning mechanism, then no. [Reid, 2013]
    • May want a lower threshold for imaging before reduction in the skeletally immature patients (<14 years of age).


Shoulder Dislocation Management

  1. Don’t be cruel… Manage the pain!
    • Consider some intranasal meds to start with.
    • Consider an intra-articular injection.
      • May use ultrasound guidance to assist with this. [Breslin, 2014]
    • May require procedural sedation – especially if it has been out for a prolonged time.
  2. Be gentle!
    • Do not use forceful jerking or attempt to leverage the humeral head over the glenoid.
    • Take your time to learn several methods (
  3. Place in sling. 
    • Conventional therapy is to immobilize for ~3 weeks.
    • This will be followed by aggressive physical therapy for most.
  4. Post-reduction plain films with axillary view.
  5. Arrange for ortho follow-up as they will need physical therapy to help them recover.
    • There is debate about the best management strategy for primary dislocations in children. [Xinning, 2013]
    • For active, young, adults, early surgical stabilization may be beneficial.
      • Especially true for those with evidence of Bankart lesion on MRI.
    • For skeletally immature children (<14 years of age), nonsurgical options are generally favored.
      • This age group has a lower rate of recurrent instability of the joint.
      • If recurrence occurs, surgical correction will be needed, but often it is delayed until skeletal maturity. [Bishop, 2005]



Breslin K1, Boniface K, Cohen J. Ultrasound-guided intra-articular lidocaine block for reduction of anterior shoulder dislocation in the pediatric emergency department. Pediatr Emerg Care. 2014 Mar;30(3):217-20. PMID: 24589815. [PubMed] [Read by QxMD]

Reid S1, Liu M, Ortega H. Anterior shoulder dislocations in pediatric patients: are routine prereduction radiographs necessary? Pediatr Emerg Care. 2013 Jan;29(1):39-42. PMID: 23283261. [PubMed] [Read by QxMD]

Li X1, Ma R, Nielsen NM, Gulotta LV, Dines JS, Owens BD. Management of shoulder instability in the skeletally immature patient. J Am Acad Orthop Surg. 2013 Sep;21(9):529-37. PMID: 23996984. [PubMed] [Read by QxMD]

Zacchilli MA1, Owens BD. Epidemiology of shoulder dislocations presenting to emergency departments in the United States. J Bone Joint Surg Am. 2010 Mar;92(3):542-9. PMID: 20194311. [PubMed] [Read by QxMD]

Bishop JY1, Flatow EL. Pediatric shoulder trauma. Clin Orthop Relat Res. 2005 Mar;(432):41-8. PMID: 15738802. [PubMed] [Read by QxMD]

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C. Diff in Kids Fri, 24 Jul 2015 11:00:06 +0000 Obviously diarrheal illness can be quite debilitating and even devastating in children.  Often the main concern is Dehydration and that focusing on...

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C Diff

Obviously diarrheal illness can be quite debilitating and even devastating in children.  Often the main concern is Dehydration and that focusing on Oral Rehydration Therapy many of these children will do just fine.  While most often the diarrhea is due to a non-specific “virus,” there are a few specific considerations that may cross your mind, like HUS or Salmonella.  In addition, one consideration that is often thought of in adults, but perhaps overlooked in children, is C. Diff.


C. Diff Basics

  • Clostridium difficile (C. Diff) is a spore-forming, obligate anaerobic, Gram-Positive bacillus.
  • It produces toxins (Toxin A and B) that lead to intestinal injury.
  • It is the MOST COMMON cause of antibiotic-associated diarrhea.
  • C. Diff incidence has been increasing in hospitalized children. [Zilberger, 2010]
  • C. Diff infection is associated with longer hospitalizations and increased mortality. [Sammons, 2013]
  • Recent evidence also describes the importance of antibiotic stewardship and community-associated cases. [Khanna, 2012Wendt, 2014]


C. Diff Diagnosis

  • The diagnosis of C. Diff disease is based on the presence of diarrhea and C. difficile toxins in a diarrheal stool specimen. [Schutze, 2013]
  • Isolation of the organism is not clinically useful.
  • Testing for the toxin is preferred.
  • Testing by age: [Schutze, 2013]
    • < 1 year of age, so avoid routine testing.
      • Asymptomatic carriage is common.
      • Testing should be limited to those with motility disorders (ex, Hirshsprung’s disease) or during an outbreak.
    • 1-3 years of life, search for other alternatives first.
      • Interpretation of results is challenging.
      • A positive result may indicate C. Diff infection.
    • After 3 years of life, a positive result indicates probably infection.
      • Still needs to be interpreted within the clinical setting.
      • The mere presence of a virulent pathogen does not necessary mean that that pathogen is the cause of the patients current symptoms. [Denno, 2012]
      • Pediatric oncology patients can also harbor C. Diff and be asymptomatic. [Dominguez, 2014]
      • To recap… C. Diff disease is Difficult to diagnosis accurately.
  • Do not “test for cure” as the toxin, the organism, and its genome are present for long periods after resolution of diarrhea. [Schutze, 2013]


C. Diff Therapy

  1. First stop the offending antimicrobial therapy!
    • May be sufficient enough to resolve symptoms.
  2. Avoid anti-peristaltic medications.
    • May worsen condition and lead to toxic megacolon.
  3. Oral Metronidazole is the drug of choice for initial therapy.
    • 30mg/kg/day in 4 divided doses, Max 2 grams/day.
    • Metronidazole-resistant C. Diff is rare.
  4. For severe disease/non-responders to 1st line, oral vancomycin or rectal vancomycin with or without IV metronidazole is used.
    • Oral vancomycin 40mg/kg/day in 4 divided doses, Max 2 grams/day.
    • Severe disease is more likely in patients with neutropenia, or intestinal stasis (ex, Hirshsprung’s disease).
  5. Up to 30% will have a recurrence after therapy ends.



Dominguez SR1, Dolan SA2, West K2, Dantes RB3, Epson E4, Friedman D5, Littlehorn CA6, Arms LE6, Walton K5, Servetar E5, Frank DN7, Kotter CV7, Dowell E6, Gould CV8, Hilden JM9, Todd JK1. High colonization rate and prolonged shedding of Clostridium difficile in pediatric oncology patients. Clin Infect Dis. 2014 Aug;59(3):401-3. PMID: 24785235. [PubMed] [Read by QxMD]

Martinelli M1, Strisciuglio C, Veres G, Paerregaard A, Pavic AM, Aloi M, Martín-de-Carpi J, Levine A, Turner D, Del Pezzo M, Staiano A, Miele E; Porto IBD Working Group of European Society for Pediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN). Clostridium difficile and pediatric inflammatory bowel disease: a prospective, comparative, multicenter, ESPGHAN study. Inflamm Bowel Dis. 2014 Dec;20(12):2219-25. PMID: 25268634. [PubMed] [Read by QxMD]

Wendt JM1, Cohen JA, Mu Y, Dumyati GK, Dunn JR, Holzbauer SM, Winston LG, Johnston HL, Meek JI, Farley MM, Wilson LE, Phipps EC, Beldavs ZG, Gerding DN, McDonald LC, Gould CV, Lessa FC. Clostridium difficile infection among children across diverse US geographic locations. Pediatrics. 2014 Apr;133(4):651-8. PMID: 24590748. [PubMed] [Read by QxMD]

Schutze GE, Willoughby RE; Committee on Infectious Diseases; American Academy of Pediatrics. Clostridium difficile infection in infants and children. Pediatrics. 2013 Jan;131(1):196-200. PMID: 23277317. [PubMed] [Read by QxMD]

Denno DM1, Shaikh N, Stapp JR, Qin X, Hutter CM, Hoffman V, Mooney JC, Wood KM, Stevens HJ, Jones R, Tarr PI, Klein EJ. Diarrhea etiology in a pediatric emergency department: a case control study. Clin Infect Dis. 2012 Oct;55(7):897-904. PMID: 22700832. [PubMed] [Read by QxMD]

Khanna S1, Baddour LM, Huskins WC, Kammer PP, Faubion WA, Zinsmeister AR, Harmsen WS, Pardi DS. The epidemiology of Clostridium difficile infection in children: a population-based study. Clin Infect Dis. 2013 May;56(10):1401-6. PMID: 23408679. [PubMed] [Read by QxMD]

Sammons JS1, Localio R, Xiao R, Coffin SE, Zaoutis T. Clostridium difficile infection is associated with increased risk of death and prolonged hospitalization in children. Clin Infect Dis. 2013 Jul;57(1):1-8. PMID: 23532470. [PubMed] [Read by QxMD]

Zilberberg MD1, Tillotson GS, McDonald C. Clostridium difficile infections among hospitalized children, United States, 1997-2006. Emerg Infect Dis. 2010 Apr;16(4):604-9. PMID: 20350373. [PubMed] [Read by QxMD]

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Pheochromocytoma Fri, 17 Jul 2015 14:16:33 +0000   The PedEM Morsels often focus on remaining vigilant. That certainly does not mean ordering a million unnecessary tests, but rather...

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The PedEM Morsels often focus on remaining vigilant. That certainly does not mean ordering a million unnecessary tests, but rather strives to augment our awareness of the complex systems we evaluate and appreciate that certainty is a fool’s proclamation. While we easily consider the common emergencies, let us not forget that there are devastating “Zebras” that are just as able to trample us and our patients. We have discussed several before (ex, Osterosarcoma, Grandenigo’s Syndrome) and we have also covered an uncommonly encountered finding of Hypertensive Emergency. These two concepts bring to mind another zebra: Pheochromocytoma.


Pheochromocytoma Basics

  • Arise from neural crest cell derived organs, known as paraganglia.
    • “Pheochromocytoma” is term used for catecholamine-secreting tumors that occur in adrenal medulla.
    • “Paraganlioma” is term for extra-adrenal tumors and can be derived from sympathetic or parasympathetic paraganglia.
    • Best to not interchange the two terms as they have different genetics, presentations, and malignant potential. [Waguespack, 2010]
  • Rare Neuroendocrine tumors
    • Comprise < 7% of sympathetic nervous system tumors.
    • ~10-20% are diagnosed during childhood.
    • Average age of childhood diagnosis = 11 years
  • Synthesize and secrete catecholamines
    • Dopamine, Norepinephrine, and Epinephrine
  • Synthesize and secrete catecholamine metabolites
    • Homovanillic acid, Normetanephrine, and Metanephrine


Pheochromocytoma and Genes

  • May occur sporadically, although often are found to have identified genetic mutations
  • May occur in association with hereditary syndrome
    • von Hipple-Lindau disease
    • Multiple Endocrine Neoplasia (MEN) 2A and 2B
    • Familial Paraganglioma Syndromes
    • Neurofibromatosis type 1
    • Tuberous Sclerosis complex
  • Rarely cause malignancy [Allan, 2013]


Pheochromocytoma Presentations

  • Mass effects of tumor
    • Ex: pain from compression of adjacent structures
    • Less common in children
  • Functional tumors secrete catecholamines
    • Presentation related to various catecholamines
    • Patient’s sensitivity to catecholamines also plays role.
    • Symptoms: [Waguespack, 2010]
      • Headache, Palpitations, Diaphoresis = “Classic” triad
      • Hypertension
      • Syncope
      • Pallor
      • Anxiety! 
      • End Organ Injury
        • Cardiomyopathy
        • CVA
        • Pancreatitis
        • Death (the ultimate end organ damage)
      • Symptoms from ectopic hormone production
        • Gigantism
        • Cushing syndrome
        • SIADH
        • Hypercalcemia
        • Secretory Diarrhea (vasoactive intestinal peptide)


Pheochromocytoma Diagnosis

  • First, we have to think of it!
    • Is this presentation “simple anxiety” or is it consistent with episodic catecholamine surges?
  •  Diagnostic tests of choice for secretory tumors
    • Urine metanephrines and normetanephrines
    • Plasma metanephrines and normetanephrines
      • Sample needs to be obtained after the “terror” of placing the IV has passed.
        • Recommended to be obtained with patient in supine position 3o minutes after IV placement.
      • Age appropriate reference ranges should be used. [Weise, 2002]


Pheochromocytoma Initial Therapies

  • No universally accepted management plan, particularly for kids. [Waguespack, 2010]
  • Alpha Blockade 
    • Improves symptoms and lowers BP.
    • Cause reflex tachycardia
    • Examples:
      • Phentolamine – short acting
      • Phenoxybenzamine – long acting (often used in while awaiting surgery)
      • Prazosin
      • Doxazosin
  • Calcium Channel blockers
    • Nicardipine
  • Beta-Blockade
    • Beta-blockers can help control reflex tachycardia seen after alpha-blockers.
    • Use before alpha-blockers can lead to unopposed alpha effects and worsening hypertension
  • Ultimately, resection of the tumors are required, which can be tricky as hypotension often results after removal of the catecholamine source. [Kalra, 2012]



Bausch B1, Wellner U, Bausch D, Schiavi F, Barontini M, Sanso G, Walz MK, Peczkowska M, Weryha G, Dall’igna P, Cecchetto G, Bisogno G, Moeller LC, Bockenhauer D, Patocs A, Rácz K, Zabolotnyi D, Yaremchuk S, Dzivite-Krisane I, Castinetti F, Taieb D, Malinoc A, von Dobschuetz E, Roessler J, Schmid KW, Opocher G, Eng C, Neumann HP. Long-term prognosis of patients with pediatric pheochromocytoma. Endocr Relat Cancer. 2013 Dec 16;21(1):17-25. PMID: 24169644. [PubMed] [Read by QxMD]

Allan B1, Davis J, Perez E, Lew J, Sola J. Malignant neuroendocrine tumors: incidence and outcomes in pediatric patients. Eur J Pediatr Surg. 2013 Oct;23(5):394-9. PMID: 23444065. [PubMed] [Read by QxMD]

Kalra Y1, Agarwal HS, Smith AH. Perioperative management of pheochromocytoma and catecholamine-induced dilated cardiomyopathy in a pediatric patient. Pediatr Cardiol. 2013;34(8):2013-6. PMID: 23132179. [PubMed] [Read by QxMD]

Sarathi V1, Pandit R, Patil VK, Lia AR, Bandgar TR, Shah NS. Performance of plasma fractionated free metanephrines by enzyme immunoassay in the diagnosis of pheochromocytoma and paraganglioma in children. Endocr Pract. 2012 Sep-Oct;18(5):694-9. PMID: 22982790. [PubMed] [Read by QxMD]

Waguespack SG1, Rich T, Grubbs E, Ying AK, Perrier ND, Ayala-Ramirez M, Jimenez C. A current review of the etiology, diagnosis, and treatment of pediatric pheochromocytoma and paraganglioma. J Clin Endocrinol Metab. 2010 May;95(5):2023-37. PMID: 20215394. [PubMed] [Read by QxMD]

Weise M1, Merke DP, Pacak K, Walther MM, Eisenhofer G. Utility of plasma free metanephrines for detecting childhood pheochromocytoma. J Clin Endocrinol Metab. 2002 May;87(5):1955-60. PMID: 11994324. [PubMed] [Read by QxMD]

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Pericarditis Fri, 10 Jul 2015 16:44:22 +0000 Chest pain as a complaint warrants great concern in our adult patients, but in children it is often perceived as benign...

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Chest pain as a complaint warrants great concern in our adult patients, but in children it is often perceived as benign by default.  Naturally, there are a number of entities that are of concern that should be considered before we jump to the “it’s costochondritis” speech with families.  We have discussed several causes of chest pain in the past (ex, myocarditis, pulmonary embolism, pneumomediastinum, spontaneous pneumothorax), but one that deserves some attention now is Pericarditis.



  • Pericardium has a visceral and parietal layer
  • Small amount of fluid (~35mL of ultra filtrate of plasma) contained within sac normally.
  • Functions to:
    • Maintain orientation between great vessels and heart
    • Prevent sudden dilation of ventricle during exercise/exertion
    • Assist in atrial filling (negative intra-pericardial pressure)
    • Acts as barrier to spread of infections from lungs to heart.


Pericarditis Recent Numbers:

  • True incidence of pericarditis is likely under-estimated in children.
  • Male predominance (~80%) [Shakti, 2014]
    • Male adolescents constituted ~50% of this study group
  • Median Age = 14.5 years (range 7 – 17 years) [Shakti, 2014]
  • Pericardial drainage was performed in 17.7% of cases [Shakti, 2014]
  • Generally a benign, self-limited course.
    • 60% recover in 1 week.
    • ~30% can develop recurrent pain.
  • Readmission occurred in ~10% of cases. [Shakti, 2014]
    • No therapeutic or underlying medical condition more associated with readmissions.

Pericarditis Causes:

  • Idiopathic (37%-68%) [Ratnapalan, 2011]
  • Infections
    • Viral (ex, coxsackievirus, EPV, influenza)
    • Bacterial
    • Fungal
  • Metabolic (ex, uremia, myxedema)
  • Rheumatic Disease (ex, Lupus, Rheumatic Fever) (~30%) [Roodpeyma, 2000]
  • Neoplastic Disease (~10%) [Roodpeyma, 2000]
  • Medication Adverse Reaction (ex, hydralazine, isoniazid)
  • Trauma


Pericarditis Presentations:

  • “Classic Triad” = fever, dyspnea, and chest pain
    • Of course, that sounds like pneumonia also.
  • 96% of acute pericarditis present with Chest Pain [Ratnapalan, 2011]
    • Often described as sharp, but can be dull.
    • Often worse with leaning backward, deep breaths, or coughing.
    • Often referred pain to shoulder, epigastric region, and/or back.
  • 56% presented with fever [Ratnapalan, 2011]
  • Pericardial friction rub may not be heard
    • Especially if there is a large effusion
    • Heard best during expiration and with child leaning forward.


Pericarditis Evaluation:

  • ALL children in one study had abnormal ECGs [Ratnapalan, 2011]
    • May not have the classic diffuse ST elevations with PR depressions and no reciprocal changes… but may have subtle T wave flattening.
    • See Dr. Mattu’s prior talks on ECG changes (Pericarditis vs STEMI; Spodick Sign)
    • Low threshold to obtain ECG in kids with Chest Pain.
  • CXR – can be helpful, but may be normal in up to 40% [Ratnapalan, 2011]
  • U/S – 82% had a pericardial effusion [Ratnapalan, 2011]
  • Labs:
    • No lab diagnoses pericarditis.
    • Several can help “complete the picture” that was started by the history and physical exam and supported by ECG and U/S.
      • ESR, CRP, and Troponin have all been shown to be elevated with acute pericarditis.


Pericarditis Therapy

  • First make sure there is no cardiovascular compromise (i.e., tamponade).
    • Again, bedside U/S is very helpful here!
    • Pericardiocentesis:
      • NOT indicated for routine investigations / management. [Durani,2010]
      • Do use for tamponade physiology.
      • Do use if concern for bacterial pericarditis.
  • Control inflammation.
    • NSAIDs are 1st-line.
    • Corticosteroids are usually reserved for severe or refractory cases.
    • Colchicine has been recently shown to be helpful in adults with acute pericarditis (See CMC Core Concept), but this is not yet an often used therapy in children. [Shakti, 2014]
  • Treat infection if present!
    • If bacterial pericarditis is suspected, initial treatment should include antistaphylococcal agents.
    • Delayed therapy in these cases is associated with high morbidity and mortality.
  • Contemplate other causes… is this uremia, is this Lupus?




Shakti D1, Hehn R1, Gauvreau K1, Sundel RP2, Newburger JW1. Idiopathic pericarditis and pericardial effusion in children: contemporary epidemiology and management. J Am Heart Assoc. 2014 Nov 7;3(6):e001483. PMID: 25380671. [PubMed] [Read by QxMD]

Brown JL1, Hirsh DA, Mahle WT. Use of troponin as a screen for chest pain in the pediatric emergency department. Pediatr Cardiol. 2012 Feb;33(2):337-42. PMID: 22089143. [PubMed] [Read by QxMD]

Ratnapalan S1, Brown K, Benson L. Children presenting with acute pericarditis to the emergency department. Pediatr Emerg Care. 2011 Jul;27(7):581-5. PMID: 21712753. [PubMed] [Read by QxMD]

Drossner DM1, Hirsh DA, Sturm JJ, Mahle WT, Goo DJ, Massey R, Simon HK. Cardiac disease in pediatric patients presenting to a pediatric ED with chest pain. Am J Emerg Med. 2011 Jul;29(6):632-8. PMID: 20627219. [PubMed] [Read by QxMD]

Roodpeyma S1, Sadeghian N. Acute pericarditis in childhood: a 10-year experience. Pediatr Cardiol. 2000 Jul-Aug;21(4):363-7. PMID: 10865014. [PubMed] [Read by QxMD]

Durani Y1, Giordano K, Goudie BW. Myocarditis and pericarditis in children. Pediatr Clin North Am. 2010 Dec;57(6):1281-303. PMID: 21111118. [PubMed] [Read by QxMD]

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Dystonic Reactions Fri, 03 Jul 2015 15:59:11 +0000 Our job can be deeply satisfying. When you are able to relieve a patient’s pain or able to help detect impending...

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Our job can be deeply satisfying. When you are able to relieve a patient’s pain or able to help detect impending disaster and avoid it, you feel like a superhero. Sometimes something as simple a fixing a Nursemaid’s Elbow will make your day! On the other hand, however, if you give a patient a medicine and the condition worsens you can feel like a fraud. Unfortunately, medication-induced dystonic reactions do occur even when you are striving to “first do no harm.”

Extrapyramidal Syndromes

  • Parkinsonism
    • Tremor, rigidity, mask-like facial expression, and/or bradykinesia
  • Akathisia
    • Restlessness and an internal feeling of unease
  • Dystonia
    • Abnormal tonic muscle contractions
    • Can include dyskinesias = clonic muscular contractions

Dystonic Reactions

  • Dystonia = movement disorder of sustained involuntary muscle contractions.
    • May present as twisting, abnormal postures or the neck, jaw, tongue or torso.
    • May also lead to eye deviation, dysphagia, dysarthria, or even dyspnea.
    • Buccolingual dystonia is the most common form. [Hooker, 1988]
      • Consists of dysarthria, mutism, trismus, tongue protruding or retracting, facial grimacing / distortions.
    • Torticollic dystonia is the 2nd most common form.
  • Mechanism is unclear, although thought to be due to an imbalance between cholinergic and dopaminergic stimulation.
    • Dopamine antagonists (ex, antipsychotics, antiemetics, and GI motility agents) often associated with dystonic reactions. [Derinoz, 2013]
    • Anticholinergic agents (ex, diphenhydramine) often used to treat it.
  • Does not indicate an overdose.
    • One study found 70% of dystonic reactions occurred within therapeutic doses. [Derinoz, 2013]
  • Consider over-the-counter medications (~18% in Derinoz’s study were due to OTC meds).


Common Offending Agents in the Ped ED

  • Antiemetics (ex, metoclopramide, promethazine)
    • Ondansetron has practically revolutionized management in the Peds ED of vomiting, because it is less likely to cause dystonic reactions.
    • While there is less risk of dysonia with ondansetron, it still can occur. [Sprung, 2003]
  • Antipsychotics (ex, Haloperidol, Risperidone, Chlorpromazine)
  • Antiepileptics (ex, Pheytoin, Carbamazepine)
  • Sedatives (ex, Benzodiazepines) [Hooker, 1988]
    • Paradoxical Reactions can also be seen with Benzodiazepines.
    • The patient becomes agitated and delirious.
    • Flumazenil administration has been reported to be helpful to alleviate these symptoms. [Jackson, 2015]


Diphenhydramine to the Rescue

  • H1-antagonism is effective in relief of dystonic symptoms.
  • Can be given orally, intravenously, or intramuscularly.
  • Interestingly… diphenhydramine can also CAUSE dystonic reactions.


Other Entities to Consider

  • Deep space neck abscess (Retropharyngeal abscess)
  • Tetanus
  • Seizure
  • Calcium deficiency
  • Drug intoxication
  • Meningitis / Encephalitis
  • Stroke
  • Conversion disorder



Jackson BF1, Beck LA2, Losek JD1. Successful flumazenil reversal of paradoxical reaction to midazolam in a child. J Emerg Med. 2015 Mar;48(3):e67-72. PMID: 25497845. [PubMed] [Read by QxMD]

Derinoz O1, Caglar AA. Drug-induced movement disorders in children at paediatric emergency department: ‘dystonia’. Emerg Med J. 2013 Feb;30(2):130-3. PMID: 22398848. [PubMed] [Read by QxMD]

Sprung J1, Choudhry FM, Hall BA. Extrapyramidal reactions to ondansetron: cross-reactivity between ondansetron and prochlorperazine? Anesth Analg. 2003 May;96(5):1374-6, table of contents. PMID: 12707136. [PubMed] [Read by QxMD]

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Inconsolable Infant Fri, 26 Jun 2015 11:00:45 +0000 Without question, one of the most challenging tasks in life is to raise a child. The degree of difficulty of this...

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Without question, one of the most challenging tasks in life is to raise a child. The degree of difficulty of this challenge is heightened when that child becomes “inconsolable.” Since a young infant or child has a limited repertoire to convey illness, constant crying needs to be taken seriously by us in the Emergency Department. So, before you jump to the conclusion that this is merely “Colic” in the 2 month old, let us quickly highlight some entities that should be at the top of your DDx when evaluating the inconsolable child.


Inconsolable Child: A Mnemonic May Help

  • Personally, I have a difficult time remembering Mnemonics, but this one can be helpful.
    • I = Infections (ex, UTI, Meningitis, Sepsis)
    • T = Trauma (ex, Subdural Hematoma, Fractures, Non-accidental trauma)
    • C = Cardiac Disease (ex, SVT)
    • R = Reaction to meds, Reflux, Rectal/Anal Fissure
    • I = Intussusception
    • E = Eyes (ex, corneal abrasion, foreign body, glaucoma)
    • S = Strangulation, Surgical Processes (ex, Hernia, Testicular/Ovarian Torsion)


Inconsolable Child: Head to Toe Exam is Key!


Inconsolable Child: But, What About Colic?

  • Colic is certainly a possibility… but, it is a diagnosis of exclusion!
  • Colic also has some criteria… so not all crying is colic!
  • Colic:
    • 10-26% of infants experience colic
    • Excessive crying for:
      • >3 hrs per day,
      • >3 days per week,
      • >3 weeks in duration
    • Can begin as early as 2nd week of life
    • Peaks around 6th week of life
    • Should resolve by 16th week of life.


Moral of the Morsel

  • A thorough history and physical exam will be the best tool to help you determine the cause of the crying. [Freedman, 2009]
  • Be diligent: pry open the mouth, look in the diaper area, exam each appendage (large and small).
  • Don’t be in a hurry to diagnose colic!



Cohen GM1, Albertini LW. Colic. Pediatr Rev. 2012 Jul;33(7):332-3; discussion 333. PMID: 22753793. [PubMed] [Read by QxMD]
Freedman SB1, Al-Harthy N, Thull-Freedman J. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics. 2009 Mar;123(3):841-8. PMID: 19255012. [PubMed] [Read by QxMD]

Herman M1, Le A. The crying infant. Emerg Med Clin North Am. 2007 Nov;25(4):1137-59, vii. PMID: 17950139. [PubMed] [Read by QxMD]

Poole SR1. The infant with acute, unexplained, excessive crying. Pediatrics. 1991 Sep;88(3):450-5. PMID: 1881722. [PubMed] [Read by QxMD]

Harkness MJ1. Corneal abrasion in infancy as a cause of inconsolable crying. Pediatr Emerg Care. 1989 Dec;5(4):242-4. PMID: 2602200. [PubMed] [Read by QxMD]

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Pulmonary Embolism Fri, 22 May 2015 11:00:25 +0000 Last week we discussed a basic look at Chest Pain in children presenting to the ED. This sparked several questions about...

The post Pulmonary Embolism appeared first on Pediatric EM Morsels.

Red Flags

Last week we discussed a basic look at Chest Pain in children presenting to the ED. This sparked several questions about Pulmonary Embolism in children. Let us take a little more specific look at PE in kids.

Pulmonary Embolism: Rare but Real

  • National Hospital Discharge Survey – 0.9 / 100,000 children per year
  • Venous thromboembolism rates have increased over the past 2 decades. [Boulet, 2012; Raffini, 2009]
    • Consideration and detection of the condition has increased.
    • Increase use of intravascular devices (ex, central lines, PICC lines).
  • Typically found to have a bimodal distribution with highest rates found in: [Stein, 2004]
    • Kids 0-1 year of age
    • Kids 15-17 years of age
  • Mortality rate – Up to 20% with 1st diagnosis, up to 30% with recurrence


Pulmonary Embolism: Red Flags

  • Risk stratification tools:
    • PERC – not validated in children
      • When PERC was applied RETORSPECTIVELY, 84% would have been missed. [Agha, 2013]
    • Wells Criteria – not validated in children
      • Even when Wells Criteria has heart rate adjustments for age, there is still not a statistical difference between PE (+) and PE (-) children. [Biss, 2009]
    • D-Dimer
      • Not validated as a diagnostic tool in children [Biss, 2009]
      • Can be used in adolescents
      • D-Dimer may vary with age and, hence, test threshold levels are not yet known.


  • Diagnosis of Pulmonary embolism is challenging in adults, it is even more so in children… so remain vigilant (while being reasonable).
  • Risk factors for thromboembolic disease in children:
    • Obesity (50% in Agha, 2013 study]
    • Oral Contraceptive Use [38% in Agha, 2013 study]
    • Central Venous Catheter
    • Cancer
    • Congenital Heart Disease
    • Prothombotic States
      • Protein C and S Deficiency
      • Antiphospholipid Antibiodies
      • Nephrotic Syndrome
      • Systemic Lupus


Moral of the Morsel

  • The rarity of the condition can lead to complacency; remain vigilant.
  • The lack of validated decision rules may lead to over-testing; be reasonable.
  • Always actively look for Red Flags!
  • Always reconsider the Differential Diagnosis for the patient that returns for similar complaints… does the child really have a repeat “atypical pneumonia” or is it a pulmonary embolism?



Agha BS1, Sturm JJ, Simon HK, Hirsh DA. Pulmonary embolism in the pediatric emergency department. Pediatrics. 2013 Oct;132(4):663-7. PMID: 23999960. [PubMed] [Read by QxMD]

Patocka C1, Nemeth J. Pulmonary embolism in pediatrics. J Emerg Med. 2012 Jan;42(1):105-16. PMID: 21530139. [PubMed] [Read by QxMD]

Boulet SL1, Grosse SD, Thornburg CD, Yusuf H, Tsai J, Hooper WC. Trends in venous thromboembolism-related hospitalizations, 1994-2009. Pediatrics. 2012 Oct;130(4):e812-20. PMID: 22987875. [PubMed] [Read by QxMD]

Biss TT1, Brandão LR, Kahr WH, Chan AK, Williams S. Clinical probability score and D-dimer estimation lack utility in the diagnosis of childhood pulmonary embolism. J Thromb Haemost. 2009 Oct;7(10):1633-8. PMID: 19682234. [PubMed] [Read by QxMD]

Raffini L1, Huang YS, Witmer C, Feudtner C. Dramatic increase in venous thromboembolism in children’s hospitals in the United States from 2001 to 2007. Pediatrics. 2009 Oct;124(4):1001-8. PMID: 19736261. [PubMed] [Read by QxMD]

Stein PD1, Kayali F, Olson RE. Incidence of venous thromboembolism in infants and children: data from the National Hospital Discharge Survey. J Pediatr. 2004 Oct;145(4):563-5. PMID: 15480387. [PubMed] [Read by QxMD]

The post Pulmonary Embolism appeared first on Pediatric EM Morsels.

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