We all have great respect for potential airway disasters. The bouncy ball that lodges in the kids airway leading to respiratory arrest is commonly spoken off and often contemplated. We are ever ready to perform transtracheal ventilation in instances such as this when you cannot oxygenate nor ventilation (see Transtracheal Ventilation and Procedure Videos). Unfortunately, the presentation of an aspirated foreign body is often more subtle than severe.
Severe vs Subtle
- In 2001, ~ 17,537 children < 14 yrs were treated in EDs for choking-related episodes.
- Rates highest for infants (<1 yr) and decreased with age.
- Candy/gum – 19%
- Coins – 12.7%
- In 2000, 160 children < 14 yrs died from aspirated foreign bodies.
- Food substances were involved in 41% of cases.
- Severe symptoms often develop acutely and more commonly have a suspicious history for a aspirated foreign body.
- Cough, stridor, difficulty breathing
- Stupor, cyanosis, respiratory arrest.
- The history, however, may not be helpful in more subtle cases, particularly if the episode was not witnessed or the patient is not able to clearly communicate what happened (ex, infant, debilitated patient, or reluctant / embarrassed teenager).
- The classic presentation of cough, wheeze, and diminished breath sounds are only seen in 40% of patients with aspirated foreign bodies… and when present, can be misconstrued as other conditions like reactive airway disease, URI, or bronchitis.
- Sometimes aspirated foreign bodies can be completely asymptomatic initially and present later with complications of retained foreign body.
- Chronic Cough
- Recurrent pneumonia
- Recurrent / persistent “croup”
- Poorly controlled “asthma”
- Lung abscess
- Progressive respiratory distress
If you are considering the diagnosis of chronic cough or recurrent pneumonia, high on your potential DDx should be undiagnosed retained foreign body.
Tracheal vs Bronchial Foreign Body
- Patients with a tracheal foreign body are more likely to have:
- Early diagnosis compared to bronchial foreign bodies.
- Patients with a bronchial foreign body are more likely to have:
- Alternative diagnosis upon first presentation.
- Delayed Diagnosis.
- Decreased breath sounds.
Plain Radiograph Utility
- Unfortunately, plain x-rays are not adequate enough to rule-out the presence of a aspirated foreign body.
- One study that compared radiographic findings to endoscopic findings found no abnormalities on x-ray in 24% of confirmed foreign body cases.
- Their sensitivity and specificity were 68% and 67% respectively.
- As with all testing, your pre-test probability needs to be factored into the interpretation of the results.
The parents saw the child put a Leggo piece in his/her mouth and now that piece is missing and the kid has a persistent cough: a normal x-ray does not take the possibility of aspirated foreign body off of the DDx.
- Naturally, based on the above, a high index of suspicion is necessary in many cases of aspirated foreign body that present less acutely.
- For those in acute distress, support oxygenation and ventilation!
- For others, obtain plain films with the understanding of their limitations.
- Look for focal hyperinflation
- May need exhalation film (for kid who cooperates)
- May need decubitus film (for younger kid) – the dependent lung should not be normal size… if it is, it is hyperinflated.
- Focal atelectasis may also be present.
- CT Scanning may reveal material in the airway and focal airway edema, but comes with cost of radiation, and does not offer therapeutic option if foreign body present. CT may also not show rule out all foreign bodies.
- Bronchoscopy is the preferred Diagnostic and Therapeutic plan.
- Flexible Bronchoscopy may be used to define and detect the foreign body, but removal of the foreign body is often more difficult with the flexible scope.
- Rigid Bronchoscopy is the the preferred procedure for removal of the foreign body.
Center for Disease Control Morbidity and Mortality Weekly Report. Nonfatal choking-related episodes among children – United States, 2001. Oct 25, 2002; 51(42): 945 – 948.
Svedstrom E, Puhakka H, Kero P. How accurate is radiography in the diagnosis of tracheobronchial foreign bodies in children? Pediatr Radiol. 1989; 19(8): 520 – 522.
Saki N, Nikakhlagh S, Rahim F, Abshirini H. Foreign body aspirations in infancy: a 20-year experience. International Journal of Medical Sciences. 2009; 6(6): 322 – 328.
During the course of a shift in the Emergency Department, I occasionally need to remind myself to rethink my diagnosis. Fighting diagnostic momentum can be difficult. That is why we look thoroughly for “Red Flags” (like we’ve talked about with Inflammatory Bowel Disease). One condition that always makes me Slow Down my diagnostic momentum is Down’s Syndrome. Most often the significant conditions that are associated with Down’s Syndrome are detected early in infancy, but given the broad variance that exists within the phenotype, these important conditions may not present until later in life.
Conditions typically detected by Primary MD
These conditions occur so commonly in association with Down’s Syndrome that they are most often screened for and considered often.
Congenital Heart Disease
- ~50% of children with Down’s Syndrome are born with CHD.
- ASD (~45%) and VSD (~35%) are the most common.
- Often detected in neonatal period as screening Echo is recommended given high prevalence.
- Ophthalmological disease
- Congenital cataracts and glaucoma are often screened for.
- Risk increases with advancing age.
- Middle ear dysfunction
- 38-78% of patients have hearing loss.
- Often require aggressive monitoring and therapy for chronic otitis with effusion.
Conditions that require our vigilance!
These conditions are known to be associated with Down’s Syndrome, but require everyone’s vigilance and may not become apparent until presenting to the Emergency Department.
- 8% develop Seizure Disorder
- 40% of them develop Seizure disorder prior to 1 year of age.
- Develops in 1-2% of children and adolescents with Down’s Syndrome.
- Associated with joint subluxations and dislocations.
- Excessive mobility of the C1 and C2 articulation.
- An atlanto-dens space of more than 4.5 mm is determined to be subluxation with or without symptoms.
- Many times are asymptomatic, but mild symptoms may be overlooked, leading to a delayed diagnosis.
- 2% develop signs of spinal cord compression.
- Need to consider this if child complains of neck pain or is noted to have decreased mobility.
- Also need to keep in mind if you need to intubate a child with Down’s Syndrome!
- Pt’s with Down’s Syndrome are more likely than any other children to have hematologic disorders.
- Transient Myeloproliferative Disorder
- Seen in ~10% of neonates with Down’s Syndrome.
- Form of “self-limited” leukemia that regresses by age 2-3 months.
- Management is conservative.
- Some will later develop other myeloproliferative disorder.
- 1 in 300 children with Down’s Syndrome develop Acute Lymphoblastic Leukemia.
- Develops in 1%.
- Keep this high on your DDx when assessing nonspecific complaints and/or vomiting.
- see prior Morsel
- Anatomic and immunologic factors place children with Down’s Syndrome at greater risk for infections.
- Children with Down’s Syndrome are at risk for functional as well as anatomic intestinal problems!
- Can present early on and have severe symptoms, but may have anatomic anomalies that present with more minor symptoms and be overlooked until later in life.
- While children with Down’s Syndrome get constipation and viral gastroenteritis like other children, make sure you Slow Down to consider these possibilities:
Small Bowel Obstruction
- There is a well known high incidence of Duodenal obstruction associated with Down’s Syndrome.
- Duodenal stenois, atresia, and annular pancreas often result in symptoms during neonatal period.
- Symptoms may be so mild, though, that the patient has only occasional vomiting, intermittent abdominal pain, or poor weight gain over several months.
- Plain abdominal obstruction x-rays can be helpful when considering this potential issue.
Hirschsprung’s Disease (see prior Morsel)
- Found in ~ 2% of children with Down’s Syndrome.
- May present early on with delayed passage of meconium, but may also be more subtle.
- Should be considered in child with “chronic constipation” that persists despite simple laxatives.
Roizen NJ, Patterson D. Down’s Syndrome. The Lancet. 2003; 361: 1281-1289.
Smith GV, Teele RL. Delayed Diagnosis of Duodenal Obstruction in Down Syndrome. AJR. 1980; 134: 937-940.
Vigilance in the face of apparently common or benign presentations is a common theme of the PedEM Morsels. As we have said, Grandma can diagnose the gastroenteritis; we need to consider the other sinister ailments that masquerade as the benign. Rhabdomyolysis is potentially one of those masqueraders.
- Literally, lysis of skeletal muscle, with resultant muscle injury, electrolyte derangement, and potential kidney failure.
- “Classic” triad = Muscle Injury, Myoglobinuria (Dark Urine), and Renal Dysfunction
- ”Classic” does not equate to common.
- One study found only ~1% of pediatric patients had all three.
- Myalgia, muscle tenderness, and weakness are commonly seen…
- and nice and vague (I had these after my recent overnight shift).
- May have edema.
- May have fever and viral-type symptoms (malaise, nausea, vomiting).
- Look for calf pain and tenderness, gait disturbance, and refusal to walk following viral illness.
- May present with over shock.
So the child who has had an antecedent “viral” illness who now presents with a limp and you naturally consider joint pathology (ex, toxic synovitis) you should also entertain the potential for Rhabdomyolysis (viral symptoms and LE pain +/- refusing to walk).
- Any trauma that leads to muscle damage may produce rhabdomyolysis.
- Child abuse, electric injuries, overuse injuries, and crush injuries.
- Prolonged immobilization or surgical procedures also can lead to it.
- Vigorous exercise in normal individuals, as well as well-trained individuals, can cause it.
- Higher risk with impaired heat loss (high humidity, restrictive clothing, etc).
- Also consider performance-enhancing supplements.
- Viral myositis is one of the leading causes of rhabdomyolysis in children!
- Influenza is the most predominant agent, but many others can lead to rhabdomyolysis as well!
- EBV, Enterovirus, varicella, HIV, Parainfluenza, rotavirus, RSV, etc.
- Bacterial infections also can be associated with rhabdomyolysis.
- Legionella, Strep. pneumoniae, Salmonella, Staph, enterococcus, Pseudomonas, etc.
- Pt’s with sepsis are at risk of developing rhabdomyolysis.
- More than 150 drugs and toxin have been associated with rhabdomyolysis.
- Illicit drugs (ex, cocaine, ecstasy) and ETOH
- Ketamine (… say it ain’t so…)
- Any envenomation that leads to muscle damage (ex, brown recluse spider bite) can lead to rhabdomyolysis.
- Familial Causes / Inborn Errors of Metabolism
- ex, Fatty Acid Oxidation Defects, Glycogen Storage Diseases, malignant hyperthermia, muscular dystrophies
- Must consider these in the patient who has had recurrent episodes of rhabdomyolysis.
- Diabetic Ketoacidosis
- Urine dip with +heme but no or few RBCs is concerning for it.
- Myoglobinuria does not have to be present for the diagnosis however.
- Myoglobin is eliminated more rapidly than Creatine Kinase (CK).
- CK levels > 1,000 U/L is often considered diagnostic.
- Lower levels of CK are termed myositis.
Rhabdomyolysis Management in the ED
- Place on monitor and obtain 12 lead ECG (make sure you are not waiting around to find out the potassium is high).
- Treat underlying cause of the condition (ex, Seizure – stop the shaking).
- Vigorous fluid resuscitation!
- 20ml/kg to start with.
- Then run IVF at 2-3 times Maintenance to maintain Urine Output of ~1-2ml/kg/hr.
- Correct electrolyte abnormalities!
- Calcium should be given only to those with severe hyperkalemia or symptomatic hypocalcemia.
- It can deposit in the tissues.
- Additionally, during fluid resuscitation, calcium may reenter the bloodstream and actually lead to hypercalcemia.
- Monitor electrolytes frequently.
- Alkalinization of the urine:
- Not proven to be effective, but it is safe and theoretically useful.
- Start AFTER the patient has started to produce urine.
- Hemofiltration may be necessary.
Luck RP, Verbin S. Rhabdomyolysis: A reveiw of clinical presentation, etiology, diagnosis, and management. Pediatr Emerg Care. April 2008; 24(4): 262-268.
With the subtly that only Mother Nature has, the days in the Northern Hemisphere have started to get longer and become consistently warmer. This, along with the fast approaching end of the school year, heralds the beginning of summer time. Summer time certainly brings wonderful times… and a new assortment of potential hazards! While we rightly focus on bike safety and swimming safety, let us not forget the dangers of heat-related illness.
- Spectrum of disease from mild, self-limited illness to major, life-threatening conditions.
- The vast majority of patients presenting to the ED with heat-related illness will be able to be discharged from the ED (~93%).
- There majority of the morbidity and mortality associated with heat-related illness is preventable.
- Painful muscle spasms.
- Body temperature is normal. There is associated sweating. No CNS derangement.
- Treat with fluid re-hydration and pain control.
- Systemic symptoms exist – dizziness, postural hypotension, nausea, vomiting, headache, weakness, and syncope.
- Body temperature can be normal or moderately elevated. There is profuse sweating.
- Often seen in unacclimatized individuals.
- Low morbidity when treated appropriately.
- Cause is salt or water depletion.
- Treat with cooling measures and re-hydration.
- State of complete thermoregulatory failure and multiorgan system dysfunction.
- Mortality ranges from 17% to 80%.
- Present with CNS derangement: disorientation, seizures, or coma.
- Other organ system derangement: hemorrhagic complications, rhabdomyolysis, intestinal ischemia, etc.
- Classic Heatstroke
- Seen typically in extremes of ages (infants and elderly).
- Develops over a period of days.
- Skin is hot and dry.
- Exertional Heatstroke
- Most commonly seen in the <19 years of age population.
- Skin may be dry or sweating.
- Temperatures range 41.1 to 42.2 C.
- Greatest risk seen in those performing high-intensity exercise for a relatively short time span.
- Treatment requires medical stabilization (ABCs), cooling measures, and re-hydration.
- Use all means to dissipate heat (convection, conduction, evaporation, and radiation).
- Spray the skin with room-temperature water and direct fans to blow across the patients skin.
- Ice pack to groin and axilla can be added, but do not apply ice-water widely over the patient’s body surface, as this may cause vasoconstriction and impair heat dissipation.
- Continuous hemofiltration can be a useful strategy to lower the temperature and also deal with potential multi-system injury.
Prevention is Better than Therapy
I think that prevention education can be administered to anyone at any time… for instance when you are sewing the star softball player’s forehead. Here are a few pointers that parents can use to keep their kids from having heat-related injuries… and, thus, stay out of your ED.
- Schedule events during cooler hours of the days.
- Arrange to be back in cooler environments during the hottest times.
- Taking frequent breaks.
Start drinking fluids before the activity!
- Unfortunately, if they start the activity dehydrated, they are going to have a hard time becoming adequately hydrated.
Drink often during the activity!
- It is important to drink even if “not thirsty.”
- Drinking 8 – 16 ounces of fluid (water or appropriate sports drink) every 20 minutes has been recommended. This may need to be adjusted for the age and size of the child.
- AVOID caffeinated and alcoholic beverages (naturally). Excessively sugary drinks (like sodas) are also not recommended.
Know the weight of the matter!
- Knowing pre-activity weight and post-activity weight can give an indication of the actual amount of water that has been lost and, thus, needs to be replaced.
- Center for Disease Control and Prevention: Nonfatal sports and recreation heat illness treated in hospital Emergency Departments – United States, 2001-2009. Morbidity and Mortality Weekly Report. July 29, 2011; 60(29): 977-980.
- American Academy of Pediatrics Committee on Sports Medicine and Fitness. Climatic heat stress and the exercising child and adolescent. Pediatrics. 2000; 106: 158–159.
Falk B, Dotan R. Temperature regulation in elite young athletes. In The Elite Young Athlete. Chapter 8, edited by Armstrong N, McManus AM. Unionville, CT. S. Karger Publishers, Inc. 2011; 56: 126-149.
I think that we’d all agree that 144/89 is not a normal blood pressure, but it is one that those of us who have the pleasure of caring for adults will look at with almost a sense of comfort – because it isn’t 70/30 or 210/120. Unfortunately, however, this sense of reassurance cannot be had when dealing with children. Depending on the patient’s sex, age, and height, 144/89 may not only represent hypertension but may be associated with hypertensive crisis in kids!
Hypertension in Kids
- Kids are becoming more and more like “little adults.”
- The prevalence of hypertension in kids is increasing.
- Likely associated with increases in obesity and metabolic syndrome.
- Kids also now with increasing prevalence of biliary disease and kidney stones.
- Naturally, normal blood pressure varies with the age of the patient.
- For low blood pressures, we’ve discussed using the formula goal SBP = 90 + (2 x Age).
- Normal blood pressure is defined as SBP and DBP < the 90th percentile for sex, age, and height.
- Hypertension is defined as SBP and DBP > 95th percentile for sex, age, and height.
- THERE ARE CHARTS! Use them to determine the percentile… you can’t remember these numbers (or at least I cannot).
- Hypertension in kids is more likely to be secondary to another concerning cause.
- Adolescents have a higher incidence of essential hypertension, but should still have secondary causes investigated (see case of Coarctation).
- Some important etiologies to consider:
- Renal Pathology
- Hemolytic Uremic Syndrome
- Wilm’s Tumor
- Nephrotic syndromes
- Polycystic kidney disease
- Renovascular disease
- Coarctation of the Aorta
- Thyroid disease
- Collagen Vascular Disease
- Periarteritis nodosa
- DRUGS (especially with those crafty teenagers)
- Anabolic Steroids
Hypertensive Crisis in Kids
- Hypertensive crisis occurs when there is accelerated hypertension in association with end-organ damage.
- Common symptoms:
- Headache (#1 complaint)
- Nausea & Vomiting
- Chest Pain / Left heart failure
- Status Epilepticus
- Initial Evaluation
- Four Limb pulses and blood pressures
- Chemistry panel
- Fundoscopic exam (papilledema?)
- Abdominal bruits?
- Draw and hold additional blood for subspecialist’s requests (ex, renin and aldoesterone levels)
- Some Therapeutic Options
- Nicardipine: FIRST LINE Tx. no negative inotropic effects. – onset ~15 min, 1/2 life = 10-15 min
- Labetalol: potentially worsens hyperkalemia. Has negative inotropic effects. 1/2 life 3-5 hrs.
- Nitroprusside: Need to keep cyanide toxicity on your radar screen!
- Esmolol: Useful after congenital heart disease repair. 1/2 life 10 min.
- Fenoldopam: Safe with renal disease. Increases renal blood flow and induces natriuresis.
GOAL: Decrease blood pressure by no more than 25-30% of original value during first 8 hrs.
Convulsion due to HTN or HTN due to Convulsion?
- Hypertensive crisis can provoke convulsions: Seizures can increase blood pressure.
- How can you differentiate between the two and select the most appropriate therapies?
- Study published in Critical Care Medicine found that a SBP or DBP of greater than 4 Standard Deviations above the average for the age is 78% predictive for the presence of hypertensive crisis. Values lower than this level had a negative predictive value of 100% (excluded hypertensive crisis).
- The Cutoff BP = ([4 x Standard Deviation for age] + Mean BP for age); which equates to the following:
- 1 mnth – 130/97
- 1 yr – 144/89
- 6 yrs – 137/100
- 12 yrs – 153/106
- 1 mnth – 126/95
- 1 yr – 143/89
- 6 yrs – 136/98
- 12 yrs – 149/105
Proulx F, LaCroix J, Farrell CA, Gauthier M. Convulsions and hypertension in children: differentiating cause from effect. Critical Care Medicine. 1993; 23: 1541-1546.
Chadar J, Zilleruelo G. Hypertensive crisis in children. Pediatric Nephrology. 2012; 27: 741-751.
We have all been there: listening to the family describe, with great concern, the apparent tremendous volume of emesis that their child produced prompting the ED visit. Everyone is knowledgeable about “dehydration” and is aware of the potential dangers it entails. Additionally, watching your child spew forth foul liquid in a manner only Linda Blair’s character, Reagan, in the Exorcist could rival is quite traumatic for parents. Fortunately, we have Ondansetron and are often able to make the flow of vomit diminish; however, in all honesty, it is the amount of diarrhea that will more likely lead to dehydration. What can be done for diarrhea and dehydration?
We have already reinforced the efficacy of Oral Rehydration Solutions in the treating dehydration. What, however, can you tell the family to help prevent dehydration in the first place?
It’s about volume!
- While, it is difficult to truly measure the amount of emesis or diarrhea, most recommend the following:
- For every episode of emesis, replete 2ml/kg.
- For every episode of diarrhea, replete 10ml/kg.
- Use an acceptable Oral Rehydration Solution to help maintain hydration.
- Fluids with too much sugar (ex, fruit juice) can lead to greater osmotic load in the intestinal lumen, producing more diarrhea.
Give the family something tangible!
- Honestly, it is a little annoying to bring your kid to the doctor’s only to get a pat on the head and hear that “it’s a virus.”
- You, certainly, may be correct in that diagnosis, but you will not be perceived in a good light.
- Instead, give the family something tangible: some knowledge on how to appropriately replete volume losses.
- Telling the family to give 10ml/kg for every episode of diarrhea won’t easily produce the results you were looking for.
- Instead, give them tangible goals based on that information.
- For instance, let’s consider a 6 month old who weighs ~8kg
- After each episode of diarrhea, we would recommend 80mL of formula / breastmilk / oral rehydration solution.
- 30mL = 1 oz
- So, if the child consumes about 2.5 oz for every episode of diarrhea, the family can help prevent dehydration.
- Families understand this concept much better, as their lives often focus on fluid ounces, particularly early on in the child’s life.
- It can be useful to write out this goal on a prescription or other discharge instructions.
- Typically, parents are highly focused on routines and what the typical quantities that are consumed by their child.
- Gentle readjustment of these expectations is important: “When I don’t feel well, I don’t eat a huge meal either.”
- The focus should not be on getting the kid to consume what he/she normally does, but rather preventing dehydration.
- If we utilize the information above, and encourage consumption of smaller amounts more frequently, the family can be successful at preventing a return visit to the ED.
Spend extra time now to prevent another visit
- Most families do not enjoy coming to the ED, but do so out of concern for their child. I think we can all respect that.
- It is easy to become crass because we are inundated with multiple patients who have a benign etiology of their vomiting and diarrhea.
- Take a few extra minutes to sit down and explain simple interventions that may prevent a return ED visit (which your colleagues will appreciate).
- Readjust expectations.
- Discuss dehydration and how to prevent it.
- Give tangible information (and write it down).
- Discuss potential for Probiotics in diminishing diarrhea.
So, while many of us don’t want to admit it, a lot of what we do in the Emergency Department does not specifically qualify as an “emergency.” Of course, while what constitutes an emergency is somewhat relative to the individual, for those issues that aren’t meeting our standards of what an emergency is, it is easy to become judgmental and crass.
Some, non-emergent conditions, however, do benefit from our attention. Many times your keen eye can help detect smoldering problems that could become more significant medical issues. Being able to keep an active pursuit of hidden illness will allow you to pick up on diabetes before it presents as DKA. Another great example is Malignant Melanoma. Simply inspecting the skin can save a life! And in kids, it is generally a lot easier to see all of their skin than in adults (bonus of working with kids!).
Malignant Melanoma in Children
- It is the most common skin cancer in those <20 years of age.
- While absolute numbers define it as a rare condition, it has been increasing in incidence.
- Recent study (Pediatrics 2013) demonstrates that the incidence of melanoma has been increasing each year since 1973.
- Overall, pediatric melanoma increased by an average of 2% per year.
- Highest incidence rates where in:
- Kids 15-19 years of age
- Low UV-B exposure (tanning beds use UV-A)
- Boys had increased incidence rates on face and trunk.
- Girls had increased incidence rates on lower limbs and hips.
- Fair skin, light colored eyes/hair (this is why I paint my children with Sunscreen even when it is snowing!)
- White race
- Female gender
- Increased number of nevi
- Increased number of childhood sunburns
- Family history of Melanoma
- INDOOR TANNING!! (we know that the sun can be dangerous… so now we use artificial suns!)
Why should an EM MD care?
- Five-year survival is currently ~100% for cases diagnosed early, while in localized stages.
- Survival drops to 82% for cases diagnosed in regional or distant stages.
- Early detection is obvious important.
- It may be the patient’s ankle pain that leads to the ED visit, but it will be your vigilance and keen eyes and mind that saves his or her life.
- Additionally, the recent publication of the increasing rates of melanoma in children will lead many to seek care where they can (often that is an ED) and many will have questions.
When should I be concerned?
- Melanoma in kids looks similar to that in adults.
- ABCD’s of Melanoma
- Borders are Irregular
- Coloration is uneven – Also be aware of moles that have been changing colors.
- Diameter > 6mm (the head of a pencil eraser)
- Increasing incidences of melanoma had also been reported in Australian children from 1983 to 1996, but a sun protection education campaign helped lead to a decreased incidence trend.
- Once again, the Aussies seem to figure these public health issues out better than my American counterparts.
Wong JR, Harris JK, Rodriguez-Galindo C, Johnson JK. Incidence of Childhood and Adolescent Melanoma in the United States: 1973-2009. Pediatrics. May 2013; 131(5):846-854.