Pediatric EM Morsels Pediatric Emergency Medicine Education Fri, 27 Feb 2015 12:00:46 +0000 en-US hourly 1 Laundry Detergent Pod Toxicity Fri, 27 Feb 2015 12:00:46 +0000   We have discussed previously how poisonings (Childhood Injury) is one of the top leading causes of death in children.  Obviously,...

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Detergent Pods


We have discussed previously how poisonings (Childhood Injury) is one of the top leading causes of death in children.  Obviously, knowing your friendly, neighborhood toxicologist or the number to the local Poison Control Center is very helpful when working in the Pediatric ED, but it is also helpful to know some of the basics and what items should raise your concern level.  Some of the most colorful and fun-looking household items can induce substantial injury and illness in children.  Let us look at an interesting one: Laundry Detergent Pod Toxicity.


Childhood Poisonings

  • In the US, > 300 children / DAY require treatment for poisonings. (CDC)
  • Over 50% of all ED visits for poisoning were for children <4 years of age. (Nalliah, 2014)
  • The majority of poisonings are unintentional in young children.
  • Over 90% of exposures occur in homes.
    • Bleach is the most common exposure.
    • Primary mechanism of exposure is ingestion.


Laundry Detergent Pod

  • Single load capsules that contain concentrated liquid detergent within a water-soluble membrane. (MMWR, 2012)
  • The water-soluble membrane dissolves once contacted by moisture (like a toddler’s mouth).
  • In 2012, 48% of the detergent exposures involved the pod variety.
  • 22% of pod exposures were associated with inappropriate storage! (Valdez, 2014)
  • The laundry detergent pod causes slightly different presentations than non-pod exposures.
    • Pod exposure occurs in younger children (5 years of age and younger).
    • Pod exposure has a higher likelihood of leading to symptoms.


Laundry Detergent Pod Toxicity: Route

  • Ingestion – most common
    • Laundry detergent pods are more likely to be ingested than other non-pod varieties. (MMWR, 2012)
    • Accounted for at least one of the exposure routes in 90% of the laundry detergent pod toxicity cases.
  • Eye exposure – 17%
    • Causes an alkaline injury! (Whitney, 2015)
    • Irrigate with copious isotonic saline until pH has become neutral.
  • Skin exposure – 11%
    • ~2% has noted 2nd and 3rd degree dermal burns (Russell, 2014)
    • Remember to expose children and remove contaminated clothing.
    • Rinse thoroughly!
  • Inhalation – 1%


Laundry Detergent Pod Toxicity: Symptoms

  • Pod exposure and non-pod exposure lead to many of the same symptoms: (MMWR, 2012)
    • Eye irritation and pain
    • Nausea
  • Pod exposure does lead to some symptoms more commonly than non-pod exposure: (MMWR, 2012)
    • Vomiting
    • Coughing/Choking
    • Drowsiness/CNS Depression
      • Unclear what the cause of the CNS depression is due to from the pods.
      • Seen in ~1 – ~8% of cases. (Stromberg, 2014)
      • Combination of altered mental status and possible pulmonary injury has lead intubation, although infrequently.


Moral of the Morsel

  • Laundry Detergent Pod Toxicity can cause CNS depression!
  • It is important to ask specifically if the exposure was to one of these pods.
  • It is important to do some injury prevention
    • Remind parents to keep colorful and candy-appearing items locked up and/or out of the sight and reach of children!!



Whitney RE1, Baum CR, Aronson PL. Diffuse corneal abrasion after ocular exposure to laundry detergent pod. Pediatr Emerg Care. 2015 Feb;31(2):127-8. PMID: 25422858. [PubMed] [Read by QxMD]

Stromberg PE1, Burt MH2, Rose SR1, Cumpston KL1, Emswiler MP1, Wills BK3. Airway compromise in children exposed to single-use laundry detergent pods: a poison center observational case series. Am J Emerg Med. 2014 Dec 3. PMID: 25592250. [PubMed] [Read by QxMD]

Sidhu N1, Jaeger MW. Concentrated liquid detergent pod ingestion in children. Pediatr Emerg Care. 2014 Dec;30(12):892-3. PMID: 25469600. [PubMed] [Read by QxMD]

Valdez AL1, Casavant MJ2, Spiller HA2, Chounthirath T3, Xiang H4, Smith GA5. Pediatric exposure to laundry detergent pods. Pediatrics. 2014 Dec;134(6):1127-35. PMID: 25384489. [PubMed] [Read by QxMD]

Russell JL1, Wiles DA, Kenney B, Spiller HA. Significant chemical burns associated with dermal exposure to laundry pod detergent. J Med Toxicol. 2014 Sep;10(3):292-4. PMID: 24526400. [PubMed] [Read by QxMD]

Nalliah RP1, Anderson IM, Lee MK, Rampa S, Allareddy V, Allareddy V. Children in the United States make close to 200,000 emergency department visits due to poisoning each year. Pediatr Emerg Care. 2014 Jul;30(7):453-7. PMID: 24977994. [PubMed] [Read by QxMD]

Beuhler MC1, Gala PK, Wolfe HA, Meaney PA, Henretig FM. Laundry detergent “pod” ingestions: a case series and discussion of recent literature. Pediatr Emerg Care. 2013 Jun;29(6):743-7. PMID: 23736069. [PubMed] [Read by QxMD]

Centers for Disease Control and Prevention (CDC). Health hazards associated with laundry detergent pods – United States, May-June 2012. MMWR Morb Mortal Wkly Rep. 2012 Oct 19;61(41):825-9. PMID: 23076090. [PubMed] [Read by QxMD]

McKenzie LB1, Ahir N, Stolz U, Nelson NG. Household cleaning product-related injuries treated in US emergency departments in 1990-2006. Pediatrics. 2010 Sep;126(3):509-16. PMID: 20679298. [PubMed] [Read by QxMD]

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Gun Safety Fri, 20 Feb 2015 12:00:06 +0000   Judging for the fact that the Post-Tonsillectomy Hemorrhage morsel gets more views than any other, I know that most of...

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Injury Prevention Guns


Judging for the fact that the Post-Tonsillectomy Hemorrhage morsel gets more views than any other, I know that most of you are interested in critical care and “exciting” topics. Certainly, your heroic efforts are occasionally necessary to help positively affect a patient’s future; however, don’t underestimate the power of some of your subtle actions.  Injury Prevention fits nicely within the arena of emergency medicine and we have discussed several topics already (ex, Submersion Prevention, Heat-Related Illness, Childhood Injuries).  There is another that we should consider when contemplating injury prevention: Gun Safety.

Now, this is not a political Morsel.  It is meant to highlight some simple points that you can use to help educate families so that their loved ones don’t come back to you as trauma patients. What follows is based on AAPs Policy Statement and other educational literature (Dowd, 2012; Crossen, 2015)

Gun-Related Deaths

  • In the US, from 2008-2010, 2,829 children (0-19 years of age) died due to gun-related injuries.
  • In 2009, 28.7% of the teenagers (15-19 yrs) that had an injury-related death, died due to a firearm-related injury.
  • Unintentional Deaths

    • Each year, an average of 134 children (0-19 years) die due to an unintentional gun-related injury.
    • Unintentional deaths occur within all age groups at almost similar incidence levels.
    • Many deaths are due to friends or siblings mishandling firearms.
    • A significant number of deaths are due to unintentional self-inflicted wounds.
  • Intentional Deaths

    • Guns are the leading mechanism for intentional death for children older than 5 years of age.
    • Suicide is the 4th leading cause of death for children 10-14 years of age.
    • Suicide is the 2nd leading cause of death for children 15-19 years of age.


What Can We Do?

Recognize the potential influential power you and your team possess in the Emergency Department.

When a patient presents with history of asthma and is wheezing, we quickly ask about smoking in the house as a means to help educate the family about the risk of continued exacerbations due to the smoke exposure.  When a patient has been involved in a minor MVC, we ask about seat belts to reinforce their utility and help prevent a future devastating injury. When a patient presents for a forearm fracture sustained after falling off a bike, we ask about whether a helmet was being worn.  These questions are asked without judgement and are useful in helping to reinforce safe behaviors to help prevent future injury.  Similarly, there are questions that we can ask to help reinforce gun safety to help prevent a child returning with a GSW.

NOTE: There are currently some states, like Florida, that have pending laws that would make it illegal for a healthcare providers to ask about firearms. While these are not currently enacted, it is always best to know your local laws.

I think that it is reasonable to ask about the presence of firearms when dealing with patients who are presenting to your Emergency Department for:

  • Injury suffered from a violent act / assault
  • Psychiatric complaint (ex, depressive symptoms, suicidal ideation)

Discussing Gun Safety

  • Counsel parents, not the kids.
    • Strategies to educate children have not demonstrated alterations in behaviors (which are often impulsive).
  • If guns cannot be removed from the home (for whatever reason), then safe storage practices are vital.
    • Use of trigger locks or cable locks
    • Use of lock boxes and gun safes
    • Storing firearms locked and unloaded
    • Storage of ammunition locked and in separate location from firearm


It is known that brief health promotional messages delivered by care providers can influence patients and their families.  It does not have to take long. It might not change the world immediately, but it might be just what that family needed to hear to help protect their child.



Crossen EJ1, Lewis B1, Hoffman BD1. Preventing gun injuries in children. Pediatr Rev. 2015 Feb;36(2):43-51. PMID: 25646308. [PubMed] [Read by QxMD]

Dowd MD, Sege RD; Council on Injury, Violence, and Poison Prevention Executive Committee; American Academy of Pediatrics. Firearm-related injuries affecting the pediatric population. Pediatrics. 2012 Nov;130(5):e1416-23. PMID: 23080412. [PubMed] [Read by QxMD]

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Koplik Spots Fri, 13 Feb 2015 12:00:42 +0000   We all know that our diagnosis is built upon the foundation of the history and physical exam. One of the...

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Koplik Spot


We all know that our diagnosis is built upon the foundation of the history and physical exam. One of the challenges in caring for children in the ED is that the physical exam can be, at times, difficult to do… particularly the oral exam.  While it may be challenging, it is incredibly important to do a thorough exam to make a timely and accurate diagnosis. The common wrestling match (you vs child) is seen during assessment for strep pharyngitis, but let us not forget that the oral exam may be very helpful in assessing the febrile child.  Is this a simple viral illness or is this measles?  Are there Koplik Spots present??


Koplik Spots: Their Appearance

  • Millimetric, erythematous, blue-white or grey speck on the buccal mucosa. (Steichen, 2009)
    • Typically appear opposite to the upper molars.
    • Can extend to include the entire buccal mucosa.
  • Seen before the external rash – about 24 hours prior.
  • Persist for 2-3 days.


Koplik Spots: Their Importance

  • With the low incidence of measles, the importance of Koplik spots may have faded from our collective memories. (Lefebvre, 2010)
    • Unfortunately, measles has not been erased from existence… so, we should still be aware and vigilant!
  • Regarded as pathognomonic of measles.
    • Seen in 50-70% of patients with measles, if examined early on in the course.
    • Koplik spots are highly predictive of confirmed measles. (Tenner, 2012)
  • Detecting Koplik spots may enable prompt measles management and control measures. (Tenner, 2012)


Early Detection is Imperative!

  • Measles is a leading cause of preventable childhood morbidity and mortality worldwide.
  • Measles is one of the most contagious disease known!
    • It is spread through aerosol exposure or contact.
    • It has a 90% transmission rate!
  • Initially, it presents similar to every other febrile, viral illness (cough, coryza, and conjunctivitis).
  • The patient is contagious for ~5 days after the onset of symptoms (yup, when that simple fever started).
  • Early detection is key to limit its spread.
    • Unfortunately, since it may look just like every other viral URI at first… combined with the fact that measles is not encountered that commonly in the US (until, recently)… it may be difficult to detect it early.
    • Koplik Spots may be the key to help you make the diagnosis… but you have to look for them!


The Oral Exam: Some Tips

For whatever reason, most kids don’t like strangers looking into their mouths.  This seems to be even more true when they don’t feel well.  Given the fact that finding Koplik spots would dramatically change your management plan, it is imperative that you examine the mouth well.  You probably shouldn’t just give ketamine to everyone who has a fever though… so what can you do?

  1. Don’t be scary.
    • No one wants a stranger prying open their mouth… so don’t be a stranger.
    • Play with the child before jumping to the mouth exam.
    • Or, at least start with areas of the exam that are less intimidating (ex, feet).
  2. Make your first attempt your best attempt.
    • This applies to all procedures… from intubation to lumbar puncture.
    • Rate of success decreases proportionally with each successive attempt
      • This is not scientific, but true…
      • Ok, it might actually be an exponential relationship.
    • Have your tools handy, but hidden…
      • Using ungloved fingers isn’t wise and realizing you need a tongue blade after starting isn’t encouraging for the family.
      • Lighting is imperative!
        • Headlamps are awesome… but a little scary… unless you are super cool and can convince them that you are a quirky Cyclops (part of the fun of being a Ped EM doc… you get to play a lot).
        • The small Mac Blade laryngoscope is ideal.  Consider it a lighted tongue blade.
    • Teach the family how you want them to hold the child before you start.
      • Learning while the child is kicking them in the face is difficult.
      • The traditional method is having the child sitting facing you with parent restraining legs, arms, and head.
  3. Have a Plan C
    • Another option for restraining, that works well, but is a bit odd:
      • Have the child sit facing parent, with his/her legs wrapped around parent’s waist.
      • The child then is reclined onto the parent’s legs with his/her neck slightly extended as it reaches past the parent’s knees.
      • The parent restrains arms and legs.
      • Typically the child’s mouth opens as they are slightly upside down.
      • Be ready with your light and quick hands… and some other assistants if needed!




Li Z1, Zhao W, Ji F. “Catarrhal physiognomy” and Koplik’s spots. Braz J Infect Dis. 2013 Jul-Aug;17(4):491-2. PMID: 23665008. [PubMed] [Read by QxMD]
Zenner D1, Nacul L. Predictive power of Koplik’s spots for the diagnosis of measles. J Infect Dev Ctries. 2012 Mar 12;6(3):271-5. PMID: 22421609. [PubMed] [Read by QxMD]

Lefebvre N, Camuset G, Bui E, Christmann D, Hansmann Y. Koplik spots: a clinical sign with epidemiological implications for measles control. Dermatology. 2010;220(3):280-1. PMID: 20110626. [PubMed] [Read by QxMD]
Steichen O1, Dautheville S. Koplik spots in early measles. CMAJ. 2009 Mar 3;180(5):583. PMID: 19255085. [PubMed] [Read by QxMD]
Tierney LM Jr1, Wang KC. Images in clinical medicine. Koplik’s spots. N Engl J Med. 2006 Feb 16;354(7):740. PMID: 16481641. [PubMed] [Read by QxMD]

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Migraine Cocktail Thu, 05 Feb 2015 22:04:28 +0000   Naturally, the differential for headache in pediatric patients is vast and includes conditions ranging from strep throat to Pseudotumor and...

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Migraine Cocktail


Naturally, the differential for headache in pediatric patients is vast and includes conditions ranging from strep throat to Pseudotumor and pneumonia to AVM. Occasionally, we have to perform invasive tests like Lumbar Punctures to help evaluate the headache. Fortunately, most often the cause of the headache is not a severe pathologic one. While it may be a more benign condition in our minds, though, let us not be cavalier with the Pediatric Migraine patient.


Pediatric Migraine

  • Headaches are common in the ED
    • 2-3% of ED for all ages.
    • Account for ~1% of Ped ED visits
    • Most headaches are due to benign causes.
  • Prevalence of Pediatric Migraine
    • Difficult to know true prevalence.
    • Increases with age:
      • 3-7 yrs: 1-3%
      • 7-11yrs: 4-11%
      • by 15yrs: 8-23%
    • Typically have had 2-3 days of headache prior to ED presentation.
    • Often (>60%) have already tried abortive therapies. [Richer, 2010]
    • Most are able to be treated effectively in the ED and discharged to home. [Bachur, 2015]


Migraine Therapies for Kids

  • Ibuprofen
    • Effective and safe [Evers, 2006; Lewis, 2002]
    • Considered by many to be first line therapy, but often used by patient prior to arrival in ED.
  • Triptans
    • NOT FDA approved for use in children, and are used “off label.”
    • Evidence that NSAID is equally efficacious.
    • Sumatriptan nasal spray has been shown to be safe and efficacious for adolescents. [Lewis, 2004; Winner, 2000]
    • Combination of Sumatriptan with NSAID has shown to be effective in adolescents also. [Derosier, 2012]
    • No ED-Based studies of use of triptans for children available yet.
  • Prochlorperazine
    • Shown to be more effective than IV NSAID (my least favorite NSAID). [Brousseau, 2004]
    • Recent publication showed that prochlorperazine use was associated with lower rate of return ED visits compared to metoclopramide (certainly not causal relationship). [Bachur, 2015]
    • Often administered with diphenhydramine to prevent akathisia, although also found to be associated with higher return ED visit rates. [Bachur, 2015]


Migraine Approach (in my humble opinion)

  • Do a thorough neuro exam!
    • Channel your inner neurologist.
    • Documenting a truly normal neuro exam goes a long way toward defining this headache as a benign one.
  • Do a Fundoscopic exam!
    • Again, let us make sure we are not missing pseudotumor… or a real tumor.
    • A PanOptic Ophthalmoscope is much easier to use on kids!
  • Headaches suck… don’t be dismissive.
    • After you have decided that this is a benign headache, realize that the kid doesn’t think it is benign.
  • Try a Triptan
    • If the patient is an adolescent, this is a reasonable option.
  • One Migraine Cocktail Coming Up.
    • There appears to be some evidence to favor Prochlorperazine over metoclopramide.
    • Keep diphenhydramine handy… remember that you should first do no harm.



Bachur RG1, Monuteaux MC2, Neuman MI2. A comparison of acute treatment regimens for migraine in the emergency department. Pediatrics. 2015 Feb;135(2):232-8. PMID: 25624377. [PubMed] [Read by QxMD]

Derosier FJ1, Lewis D, Hershey AD, Winner PK, Pearlman E, Rothner AD, Linder SL, Goodman DK, Jimenez TB, Granberry WK, Runken MC. Randomized trial of sumatriptan and naproxen sodium combination in adolescent migraine. Pediatrics. 2012 Jun;129(6):e1411-20. PMID: 22585767. [PubMed] [Read by QxMD]

Trottier ED1, Bailey B, Lucas N, Lortie A. Prochlorperazine in children with migraine: a look at its effectiveness and rate of akathisia. Am J Emerg Med. 2012 Mar;30(3):456-63. PMID: 21296523. [PubMed] [Read by QxMD]

Richer LP1, Laycock K, Millar K, Fitzpatrick E, Khangura S, Bhatt M, Guimont C, Neto G, Noseworthy S, Siemens R, Gouin S, Rowe BH; Pediatric Emergency Research Canada Emergency Department Migraine Group. Treatment of children with migraine in emergency departments: national practice variation study. Pediatrics. 2010 Jul;126(1):e150-5. PMID: 20530076. [PubMed] [Read by QxMD]

Evers S1, Rahmann A, Kraemer C, Kurlemann G, Debus O, Husstedt IW, Frese A. Treatment of childhood migraine attacks with oral zolmitriptan and ibuprofen. Neurology. 2006 Aug 8;67(3):497-9. PMID: 16775229. [PubMed] [Read by QxMD]

Brousseau DC1, Duffy SJ, Anderson AC, Linakis JG. Treatment of pediatric migraine headaches: a randomized, double-blind trial of prochlorperazine versus ketorolac. Ann Emerg Med. 2004 Feb;43(2):256-62. PMID: 14747817. [PubMed] [Read by QxMD]

Lewis D1, Ashwal S, Hershey A, Hirtz D, Yonker M, Silberstein S; American Academy of Neurology Quality Standards Subcommittee; Practice Committee of the Child Neurology Society. Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society. Neurology. 2004 Dec 28;63(12):2215-24. PMID: 15623677. [PubMed] [Read by QxMD]

Lewis DW1, Kellstein D, Dahl G, Burke B, Frank LM, Toor S, Northam RS, White LW, Lawson L. Children’s ibuprofen suspension for the acute treatment of pediatric migraine. Headache. 2002 Sep;42(8):780-6. PMID: 12390641. [PubMed] [Read by QxMD]

Winner P1, Rothner AD, Saper J, Nett R, Asgharnejad M, Laurenza A, Austin R, Peykamian M. A randomized, double-blind, placebo-controlled study of sumatriptan nasal spray in the treatment of acute migraine in adolescents. Pediatrics. 2000 Nov;106(5):989-97. PMID: 11061765. [PubMed] [Read by QxMD]

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Asthma Control Fri, 30 Jan 2015 16:59:25 +0000   I know that everyone wants to discuss critical care topics like delayed sequence intubation, management of post-tonsillectomy hemorrhage, or damage...

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Asthma Control


I know that everyone wants to discuss critical care topics like delayed sequence intubation, management of post-tonsillectomy hemorrhage, or damage control resuscitation.  I agree, they are part of what makes Emergency Medicine exciting and provocative; however, the vast majority of what we do does not require you to know how to optimize chest compressions or manage a ventilator for an intubated asthmatic.  In order to provide the best care for all of our patients and maximize the efficacy of all of our therapies, we need to know some “less exciting” topics that are never depicted on TV shows about the ED.  Determining whether your patient’s Asthma Control is sufficient is an excellent example of this.


Asthma Burden

  • 1 in 11 children have asthma  (CDC)
  • In 2010, 7 MILLION children had asthma in the US.
  • In 2009, 1 in 5 children with asthma went to the ED for their care!!
  • In North Carolina (and I am sure many others), many patients with asthma who use the ED do not identify a regular source of primary care.  (Crane, 2011)
    • The notion of “their primary care doc will follow up on that” is not realistic in many cases.
    • Helping to optimize a patient’s management is ALL of our jobs.
    • It takes a village” is a better way to think of it.


Asthma Control

Aside from managing the acute exacerbation (which we have covered many aspects of in the past: ex, MDIs, Dexamethasone, Magnesium, Hydration Status), an important question is whether this patient’s asthma control is adequate. That brings us to the question of, what defines Asthma Control? (Bousquet, 2010)

  • Well Controlled

    • Daytime symptoms: <2 or less days/week, but not more than once/day
    • Nighttime symptoms: None
    • Limitations of activities in past 2-4 wks: None
    • Need for Rescue Rx in past month: 2 or less days/week
    • Exacerbations requiring systemic steroids: 0-1 / year
  • Partially Controlled

    • Daytime symptoms: >2 days/week, >Once/day
    • Nighttime symptoms: 1-2 nights/week
    • Limitations of activities in past 2-4 wks: Some
    • Need for Rescue Rx in past month: >2 days/week
    • Exacerbations requiring systemic steroids: 2 / year
  • Poorly Controlled

    • Daytime symptoms: Throughout the day
    • Nighttime symptoms: >2 nights/week
    • Limitations of activities in past 2-4 wks: Extremely limited
    • Need for Rescue Rx in past month: Several times a day
    • Exacerbations requiring systemic steroids: >2 / year


Rule of 2’s

So, keeping the above characterizations in your mind might be challenging during a busy ED shift… so keep the Rule of 2’s stored in your cerebral cortex instead. (Singer, 2005)

  • Over the past month, Inadequate Asthma Control is indicated by:
    • Use of Rescue Inhaler 2 days/week
    • Awakening w/ symptoms 2 times/month
    • Use of 2 or more Rescue Inhalers (MDIs) / year


Why do you Care?

Yes, I understand that many do not believe that the ED is the place to discuss management strategies of chronic conditions.  I disagree.

  • The best time to get someone’s attention about their health is when they are not feeling well.
  • It may be the only time that they actually get to see a doctor about their chronic condition.
  • Determining whether their Asthma Control is inadequate and then starting an inhaled corticosteroid (or adjusting their current regimen) may be the best way to prevent that patient from having to come back to see you again in the ED.  (It is a selfish endeavor really).



Crane S1, Sailer D, Patch SC. Improving asthma care in emergency departments: results of a multihospital collaborative quality initiative in rural western North Carolina. N C Med J. 2011 Mar-Apr;72(2):111-7. PMID: 21721495. [PubMed] [Read by QxMD]

Bousquet J1, Mantzouranis E, Cruz AA, Aït-Khaled N, Baena-Cagnani CE, Bleecker ER, Brightling CE, Burney P, Bush A, Busse WW, Casale TB, Chan-Yeung M, Chen R, Chowdhury B, Chung KF, Dahl R, Drazen JM, Fabbri LM, Holgate ST, Kauffmann F, Haahtela T, Khaltaev N, Kiley JP, Masjedi MR, Mohammad Y, O’Byrne P, Partridge MR, Rabe KF, Togias A, van Weel C, Wenzel S, Zhong N, Zuberbier T. Uniform definition of asthma severity, control, and exacerbations: document presented for the World Health Organization Consultation on Severe Asthma. J Allergy Clin Immunol. 2010 Nov;126(5):926-38. PMID: 20926125. [PubMed] [Read by QxMD]

Bateman ED1, Hurd SS, Barnes PJ, Bousquet J, Drazen JM, FitzGerald M, Gibson P, Ohta K, O’Byrne P, Pedersen SE, Pizzichini E, Sullivan SD, Wenzel SE, Zar HJ. Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J. 2008 Jan;31(1):143-78. PMID: 18166595. [PubMed] [Read by QxMD]

Singer AJ1, Camargo CA Jr, Lampell M, Lewis L, Nowak R, Schafermeyer RW, O’Neil B. A call for expanding the role of the emergency physician in the care of patients with asthma. Ann Emerg Med. 2005 Mar;45(3):295-8. PMID: 15726053. [PubMed] [Read by QxMD]

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Inguinal Hernia Fri, 23 Jan 2015 12:00:03 +0000 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)
        • 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



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 Fri, 16 Jan 2015 12:00:33 +0000 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%


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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