Podcast #393: Neonatal Vomiting

Author: Peter Bakes, MD

Educational Pearls:

  • Important historical information to elicit is the birth history, feeding habits, stooling habits, associated symptoms, presence of bile, and presence of trauma.
  • Volvulus is a common etiology of intestinal obstruction and is often due to malrotation in utero.

Editor’s note: get an upper GI series if there is any bilious vomiting in a neonate. Any time of the night. Wake people up. Transfer if necessary to get the study. This can diagnose volvulus and save bowel.

References:

Ratnayake K, Kim TY. Evidence-based management of neonatal vomiting in the emergency department. Pediatr Emerg Med Pract. 2014 Nov;11(11):1-20;  Review. PubMed PMID: 25928976.

Burge DM. The management of bilious vomiting in the neonate. Early Hum Dev. 2016 Nov;102:41-45. doi: 10.1016/j.earlhumdev.2016.09.002. Epub 2016 Sep 12. Review. PubMed PMID: 27634337.

Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

Podcast #389: BRUE

Author:  Sarah Normandin, MD.

Educational Pearls:

  • BRUE (Brief Resolved Unexplained Event) replaces what was previously called ALTE.
  • BRUE describes an event in a child less than one year of age with one or more of the following:
    • cyanosis or pallor
    • absent, decreased, or irregular breathing
    • decreased or increased tone
    • altered responsiveness
  • These must be sudden, brief, and now resolved and without an alternative explanation after a history and physical exam
  • Low risk patients can be safely discharged with reassurance
  • Low risk criteria must all be present:
    • Age over 60 days old
    • >32 weeks gestational age at birth and adjusted gestational age > 45 weeks)
    • No CPR was performed (by a trained medical professional)
    • First event
    • Duration less than 1 minute of event
  • Patients who satisfy above criteria can be considered low risk and may be discharged after minimal/no workup

 

References:

Tieder JS, Bonkowsky JL, Etzel RA, et al. Clinical Practice Guideline: Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary. Pediatrics. 2016:137(5):e20160591. Pediatrics. 2016 Aug;138(2). pii: e20161488. doi: 10.1542/peds.2016-1488. PubMed PMID: 27474017.

 

Summary by Travis Barlock, MS4    |   Edited by Erik Verzemnieks, MD

Podcast # 370:  Rapid Fire Neonatal Resuscitation

Author:  Erik Verzemnieks, MD

Educational Pearls:

  • In the panic of a precipitous ED delivery, remember: Warm. Dry. Stim.  It will solve most of your problems in most scenarios
  • Start compressions if heart rate is less than 60
  • Put the pulse ox on the right hand – it may make a difference as it is preductal

Editor’s note: detecting a heart rate can be tough in a newborn – you can feel the umbilical stump or just listen with your stethoscope

 

References

Gary Weiner & Jeanette Zaichkin. Textbook of Neonatal Resuscitation (NRP), 7th Ed, 2016. American Academy of Pediatrics & American Heart Association.

Podcast # 356: Babies can’t be born addicted

Author: Don Stader, MD.

Educational Pearls:

  • A baby can be born dependent on opioids but not addicted to them.
  • Opioid addiction (Opioid Use Disorder) is a disease of mature brains and is characterized by compulsive drug use despite adverse consequences.
  • Opioid addiction is a disease that affects the reward center of the brain
  • Pregnant patients struggling with addiction do better when started on buprenorphine or methadone. This treatment will cause opioid withdrawal syndrome in newborns, but not the long term morbidity and mortality of illicit opioids.

References

Gowing L, Farrell MF, Bornemann R, Sullivan LE, Ali R. Oral substitution treatment of injecting opioid users for prevention of HIV infection. Cochrane Database of Systematic Reviews 2011, Issue 8: CD004145. DOI: 10.1002/14651858.CD004145.pub4.

Volkow ND, Koob GF, McLellan AT ( 2016). “Neurobiologic Advances from the Brain Disease Model of Addiction.” New England Journal of Medicine. 374 (4): 363?371.

Podcast # 346: Pediatric DKA

Author: Chris Holmes, MD

Educational Pearls:

  • There is a risk of cerebral edema in pediatrics with DKA if over resuscitated.
  • Recent study comparing normal saline vs. ½ normal saline showed no difference in rates of cerebral edema regardless of rate of infusion.
  • Recommend sticking with a fluid resuscitation protocol you are familiar with (i.e., 2 rounds of 10cc/kg bolus of NS).

 

References

Glaser, N. S., Ghetti, S., Casper, T. C., Dean, J. M., & Kuppermann, N. (2013). Pediatric Diabetic Ketoacidosis, Fluid Therapy and Cerebral Injury: The Design of a Factorial Randomized Controlled Trial. Pediatric Diabetes, 14(6), 435?446. http://doi.org/10.1111/pedi.12027

Podcast #315: Retropharyngeal Infections in Pediatrics

Author: Dr. Karen Woolf, MD

Educational Pearls:

  • Anatomy : base of skull to posterior mediastinum, anteriorly bounded by middle layer of deep cervical fascia and posteriorly by the deep layer, communicates to lateral pharyngeal space bounded by carotid sheath. Lymph node chains draining nasopharynx, sinuses, middle ear, etc. run through it.
  • Epidemiology & Microbiology: most common kids 2-4, (neonates too). Polymicrobial (GAS, MSSA, MRSA, respiratory anaerobes).
  • Signs and symptoms can include pharyngitis, dysphagia, odynophagia, drooling, torticollis, muffled voice, respiratory distress, stridor, neck swelling, and trismus.
  • Exam may show drooling, posterior pharyngeal swelling, anterior cervical LAD, or a neck mass.
  • Imaging: Get CT neck w/IV contrast!
  • DDx: epiglottis, croup, bacterial tracheitis, peritonsillar abscess, trauma, foreign body, angioedema, cystic hygroma, meningitis, osteomyelitis, tetanus toxin.
  • Tx: Unasyn, if not responding add Vancomycin or Linezolid; surgical drainage if airway is compromised.
  • Complications: airway obstruction, sepsis, aspiration pneumonia, IJ thrombosis, carotid artery rupture, mediastinitis.

References:

Craig FW, Schunk JE. Retropharyngeal abscess in children: clinical presentation, utility of imaging, and current management. Pediatrics 2003; 111:1394.

Fleisher GR. Infectious disease emergencies. In: Textbook of Pediatric Emergency Medicine, 5th ed, Fleisher GR, Ludwig S, Henretig FM (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.783.

Goldstein NA, Hammersclag MR. Peritonsillar, retropharyngeal, and parapharyngeal abscesses. In: Textbook of Pediatric Infectious Diseases, 6th ed, Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL (Eds), Saunders, Philadelphia 2009. P.177

Podcast #311: Recurrence of Seizures in Pediatrics

Author: Aaron Lessen, M.D.

Educational Pearls:

  • Recurrence rate for first time unprovoked seizures – 5% after 48 hours, 14% at 2 weeks , 30% after 4 months.
  • Higher risk for recurrence: age under 3; patients with multiple seizures at initial presentation, focal neurologic findings on initial presentation.
  • Useful for counseling patients and recommending follow up.

References:

Shinnar S, Berg AT, Moshé SL, et al. Risk of seizure recurrence following a first unprovoked seizure in childhood: a prospective study. Pediatrics 1990; 85:1076.

Podcast #275: Battery Ingestions

Author: Nick Hatch, M.D.

Educational Pearls

  • Unlike coin ingestions, button batteries can cause necrosis of the GI tract.
  • If lodged in the esophagus, removal within 2 hours is important, because they can cause problems such as strictures or esophago-aortic fistula.
  • If the battery is in the stomach or beyond, it may be ok to let it pass but give strict return precautions.
  • Small hearing aid batteries are not as dangerous, but still require close follow-up to ensure the battery passes.
  • Delayed effects (after passage of the battery) are possible.

References: https://www.poison.org/battery/guideline

Podcast #274: Pediatric Sedation

Author: Aaron Lessen, M.D.

Educational Pearls

  • A recent prospective observational study was performed to examine the safety of different sedation medications in the pediatric ED.
  • This study included 6000 children, and looked at the rate of serious adverse events following administration of different sedatives.
  • Overall, the safest drug to use was ketamine alone, with an adverse event rate of about 1%.
  • Propofol, BZDs, and opiates had increased rates of adverse events.

References: https://lifeinthefastlane.com/pediatric-procedural-sedation-with-ketamine/

Podcast #262: Pertussis

Author: Julian Orenstein, M.D.

Educational Pearls

  • Colorado has a high population of unvaccinated children, and is at increased risk for pertussis outbreaks.
  • The causative organism is Bordetella pertussis. It causes  causes respiratory epithelial necrosis leading to congestion of the bronchioles, leading to cough.
  • The cough is unique – it is usually a series of expiratory coughs followed by one deep inspiration
  • The clinical presentation is divided into 3 phases:
    • Catarrhal: cough and congestion with low-grade fever and coryza.
    • Whooping: characteristic cough.
    • Resolution: recovery with persistent cough.
  • Infants may not get this presentation, but may get apnea and nonspecific cough.  
  • Tongue depressor can be used to elicit cough for diagnosis.

References: Tozzi AE, Pastore Celentano L, Ciofi degli Atti ML, Salmaso S. Diagnosis and management of pertussis. CMAJ?: Canadian Medical Association Journal. 2005;172(4):509-515. doi:10.1503/cmaj.1040766.