Author: Chris Holmes, MD
- 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).
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
Author: Dr. Karen Woolf, MD
- 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.
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
Author: Aaron Lessen, M.D.
- 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.
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.
Author: Nick Hatch, M.D.
- 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.
Author: Aaron Lessen, M.D.
- 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.
Author: Julian Orenstein, M.D.
- 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.
Author: Suzanne Chilton, M.D.
- Pott’s puffy tumor is a subperiosteal abscess of the frontal bone that arises from hematologic spread or direct infection via the frontal sinuses. The primary symptom is facial swelling.
- It is much more common in children and adolescents.
- Treatment involves removal of the frontal bone, reconstructive surgery, and 6-8 weeks of IV antibiotics.
References: Grewal HS, Dangaych NS, Esposito A. A tumor that is not a tumor but it sure can kill! The American Journal of Case Reports. 2012;13:133-136. doi:10.12659/AJCR.883236.
Author: Jared Scott, M.D.
- BB gun eye injuries are most common in August and September. They most often happen to males aged 16-17 year old. Around 10% of the BB eye injuries lead to eye loss.
- Accidental firearm injury is common in children and is a common cause of mortality. One-third of homes with children have a firearm.
- Most accidental pediatric gun injuries happen to young, male children with guns owned by family members. It is important to educate gun owners about proper gun storage.
References: Childhood Firearm Injuries in the United States Katherine A. Fowler, Linda L. Dahlberg, Tadesse Haileyesus, Carmen Gutierrez, Sarah Bacon. Pediatrics Jun 2017, e20163486; DOI: 10.1542/peds.2016-3486
Author: Aaron Lessen, M.D.
- Asking parents and Broselow Tape are common options for estimating pediatric weight.
- Equipment sizes should not be adjusted for under/overweight kids based on Broselow Tape estimates.
- The finger counting method (see reference) is just as accurate as Broselow Tape method, according to one study.
Author: Michael Hunt, M.D.
- Children under age of 6 are at greatest risk of accidental nicotine overdose from ingestion.
- Biphasic presentation:
- Hyperadrenergic = nausea, vomiting, tachycardia, flushing.
- Bradycardia and respiratory depression.
Mayer B. How much nicotine kills a human? Tracing back the generally accepted lethal dose to dubious self-experiments in the nineteenth century. Archives of Toxicology. 2013;88(1):5-7. doi:10.1007/s00204-013-1127-0.