Pulmonary Embolism

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?

 

References

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.

Chest Pain

Chest Pain 2

 

Children like to pretend to be grown-ups.  Unfortunately, sometimes they develop grown-up problems (Cholelithiasis, Kidney Stones, and Hypertension).  Additionally, often kids will complain of symptoms that warrant great concern in adults, but often engender apathy when considered in children. Chest Pain is a great example of one of these complaints.

 

Chest Pain: Hysteria vs Vigilance

  • The odds are in favor of being reasonable
    • Only ~1-6% of chest pain in children is due to a cardiac cause
    • GI cause – 2-11% of chest pain
    • Musculoskeletal – 2-11% of chest pain
    • No Identifiable cause – 21-45% of the time!
  • Yet, our job requires vigilance for find the rare dangers!

 

Culprits to Consider

 

Chest Pain: Evaluation

  • The goal is to balance risk of the rare with risk of over-testing.
  • Reasonable screen for cardiac etiology [Kane, 2010]:
    • Chest Pain with Exertion?
    • High-risk family history (ex, unexplained sudden death)?
    • Abnormal exam (ex, murmurs, hepatomegaly)?
    • Abnormal ECG
  • Reasonable screen for pulmonary etiology:
    • CXR
      • Obviously useful… but perhaps leads to unnecessary imaging.
    • If pneumothorax is your primary concern, consider the Bedside Ultrasound
      • There are plenty of studies  that demonstrate that U/S is more sensitive than supine CXR in the setting of adult trauma.
        • U/S – ~90% sensitive
        • Supine CXR – ~50% sensitive
        • Erect CXR has increased sensitivity (~90%), naturally.
      • U/S is naturally operator dependent… and in this case the operator is you… so are you dependable?

Moral of the Morsel

  • For the young patient presenting with chest pain, be vigilant, but be reasonable.
  • Screen for badness with:
    • Thorough history and directed physical exam
    • ECG
    • Ultrasound and/or CXR.

 

References

Angoff GH1, Kane DA, Giddins N, Paris YM, Moran AM, Tantengco V, Rotondo KM, Arnold L, Toro-Salazar OH, Gauthier NS, Kanevsky E, Renaud A, Geggel RL, Brown DW, Fulton DR. Regional implementation of a pediatric cardiology chest pain guideline using SCAMPs methodology. Pediatrics. 2013 Oct;132(4):e1010-7. PMID: 24019419. [PubMed] [Read by QxMD]

Friedman KG1, Kane DA, Rathod RH, Renaud A, Farias M, Geggel R, Fulton DR, Lock JE, Saleeb SF. Management of pediatric chest pain using a standardized assessment and management plan. Pediatrics. 2011 Aug;128(2):239-45. PMID: 21746719. [PubMed] [Read by QxMD]

Kane DA1, Fulton DR, Saleeb S, Zhou J, Lock JE, Geggel RL. Needles in hay: chest pain as the presenting symptom in children with serious underlying cardiac pathology. Congenit Heart Dis. 2010 Jul-Aug;5(4):366-73. PMID: 20653703. [PubMed] [Read by QxMD]

Son MB1, Sundel RP. Musculoskeletal causes of pediatric chest pain. Pediatr Clin North Am. 2010 Dec;57(6):1385-95. PMID: 21111123. [PubMed] [Read by QxMD]

Selbst SM1. Approach to the child with chest pain. Pediatr Clin North Am. 2010 Dec;57(6):1221-34. PMID: 21111115. [PubMed] [Read by QxMD]

Lichtenstein DA1, Mezière G, Lascols N, Biderman P, Courret JP, Gepner A, Goldstein I, Tenoudji-Cohen M. Ultrasound diagnosis of occult pneumothorax. Crit Care Med. 2005 Jun;33(6):1231-8. PMID: 15942336. [PubMed] [Read by QxMD]

The post Chest Pain appeared first on Pediatric EM Morsels.

Pediatric Burn

Euglycemia

 

We have covered many environmental injuries in the past (ex, Lawn mower injury, Submersion Injury, Firearm Safety).  We have also addressed some basics of Pediatric Burn management, but because burns can be challenging to manage, let us revisit some issues with Pediatric Burn, like what glucose level should be the goal.

 

Pediatric Burn: Basics

  • It is estimated that every day 300 children (0-19 years) are treated in EDs for burns. (CDC.gov)
  • 2 children die every day due to burn related injuries.
  • Scalding injuries are more prevalent in children <5years of age, while flame/fire is most prevalent at all other age groups. (American Burn Association 2013 Report)

 

Pediatric Burn: TBSA Estimation

  • Calculation of the Total Body Surface Area involved in the burn is CRITICAL!
    • TBSA calculations will help determine fluid management.
    • TBSA calculations will help determine whether a patient requires transfer to Burn Facility.
  • Unfortunately, there is no perfect solution to accurately calculate the TBSA in the ED on initial exam.
    • Rule of Nines – often OVER-estimates the size of the burn
    • Lund-Browder – accounts for changes in body surface area with age, but is technically more difficult to use than Rule of Nines. Often preferred for Pediatric Burn.
    • Neither account for irregular burn patterns that do not occupy an entire designated body surface area.
    • There are “resuscitation burn cards” that offer a standardized area that can be used to help improve estimations of irregular burns. [Malic, 2007]
    • A Burn Size Score has also been recently studied as a means to improve accuracy of initial TBSA estimations. [Kahn, 2010]
  • Unfortunately, there is often a discrepancy between the TBSA initially calculated and the one the Burn Center recalculates. [Goverman,
    • TBSA calculations DO NOT include 1st Degree burns.
      • Including 1st degree burns leads to over-estimation of the burn, excessive fluid administration, and unnecessary transfers.
    • Since there are several methods to calculate TBSA, and none are perfect, it is likely best to know which method your friendly neighborhood Burn Center uses so that you can all be on the same page!

 

Pediatric Burn: Don’t Forget the Sugar!

  • We have discussed the importance of recognizing hypoglycemia in children.
  • Monitoring glucose levels in pediatric burn patients is also critical!
  • Too Low is Bad

    • Pediatric burn patients have even higher metabolic rate than normal and higher glucose requirements.
    • They also have limited alternative energy stores.
    • Pediatric Burn patients have been found to be vulnerable to hypoglycemia-induced injury. [Jeschke, 2014]
      • Hypoglycemia causes a greater inflammatory response than those without hypoglycemia. [Jeschke, 2014]

 

  • Too High is Bad

    • Critically-ill burn patients can experience stress-induced hyperglycemia and insulin resistance.
    • Hyperglycemia is associated with:
      • increased protein catabolism
      • skin graft failure
      • infection
      • sepsis
      • increased mortality
    • Tight glycemic control with insulin therapy can help avoid these complications. [Jeschke, 2010; Fram, 2010]
    • Unfortunately, this can lead to hypoglycemia.

 

  • What’s Just Right?

    • Since having glucose levels that are too high or too low seem to be suboptimal, what is the goal glucose level?
    • Glucose level of 130-140 mg/dL seems to be the best goal. [Jeschke, 2010]

 

Moral of the Morsel

  • Take the time to estimate the TBSA involved.  This will greatly influence the management!
  • Initial fluid calculations for replacement (ex, using Parkland formula) should be ADDED to maintenance fluids.
  • NEVER forget the sugar!  You don’t need to add it to their resuscitation fluids, but their maintenance fluids need glucose.
  • If the patient remains in your care for a prolonged period, don’t forget to monitor the glucose level.

 

 

References

Jeschke MG1, Pinto R, Herndon DN, Finnerty CC, Kraft R. Hypoglycemia is associated with increased postburn morbidity and mortality in pediatric patients. Crit Care Med. 2014 May;42(5):1221-31. PMID: 24368343. [PubMed] [Read by QxMD]

Goverman J1, Bittner EA, Friedstat JS, Moore M, Nozari A, Ibrahim AE, Sarhane KA, Chang PH, Sheridan RL, Fagan SP. Discrepancy in Initial Pediatric Burn Estimates and Its Impact on Fluid Resuscitation. J Burn Care Res. 2014 Nov 18. PMID: 25407387. [PubMed] [Read by QxMD]

Jeschke MG1, Kraft R, Emdad F, Kulp GA, Williams FN, Herndon DN. Glucose control in severely thermally injured pediatric patients: what glucose range should be the target? Ann Surg. 2010 Sep;252(3):521-7; discussion 527-8. PMID: 20739853. [PubMed] [Read by QxMD]

Fram RY1, Cree MG, Wolfe RR, Mlcak RP, Qian T, Chinkes DL, Herndon DN. Intensive insulin therapy improves insulin sensitivity and mitochondrial function in severely burned children. Crit Care Med. 2010 Jun;38(6):1475-83. PMID: 20400899. [PubMed] [Read by QxMD]

Jeschke MG1, Kulp GA, Kraft R, Finnerty CC, Mlcak R, Lee JO, Herndon DN. Intensive insulin therapy in severely burned pediatric patients: a prospective randomized trial. Am J Respir Crit Care Med. 2010 Aug 1;182(3):351-9. PMID: 20395554. [PubMed] [Read by QxMD]

Kahn SA1, Schoemann M, Lentz CW. Burn resuscitation index: a simple method for calculating fluid resuscitation in the burn patient. J Burn Care Res. 2010 Jul-Aug;31(4):616-23. PMID: 20489651. [PubMed] [Read by QxMD]

Malic CC1, Karoo RO, Austin O, Phipps A. Resuscitation burn card–a useful tool for burn injury assessment. Burns. 2007 Mar;33(2):195-9. PMID: 17222978. [PubMed] [Read by QxMD]

The post Pediatric Burn appeared first on Pediatric EM Morsels.

Seizure Mimics

Seizure Mimics

Few things will frighten parents more than seeing their child appear to shake all over.  Fortunately, many times seizure activity is due to benign causes like simple febrile seizures.  Unfortunately, our job is quite difficult and we need to deal with other more troublesome entities like complex febrile seizures or neonatal seizures.  Of course we also need to consider entities that may provoke seizures, like hypoglycemia, AVMs, or pyridoxine deficiency.  While juggling all of the potential causes of seizures, we also need to pause and ask ourselves a simple question: was this even a seizure?  Perhaps we are dealing with a Seizure Mimic!

 

Seizure Numbers

  • Seizures are the most common pediatric neurologic emergency.
  • Seizures affect 4-10% of children during their lifetime.  (Hauser, 1994)
  • ~10% of new onset seizures present to the ED in status epileptics. (Singh, 2010)

 

Some Seizure Mimics

Since seizures are the most common neurologic emergency encountered in pediatric patients, it is reasonable to have it on the Ddx list of any child presenting with odd movements and/or behavior; however, there are also other significant conditions that should be considered in that situation! Here are some that could alter your initial management!

  • Arrhythmias
    • Long QT and torsades
    • VTach
    • Anytime there is poor cardiac output impairing cerebral perfusion, you can see motor activity / hypoxic convulsions.
  • Breath-Holding Spells
    • Actually not associated with inspiratory hold. The child typically screams/cries and exhales fully.
    • They can loose postural tone and have motor activity.
    • Up to 15% will have generalize hypoxic convulsions. (DiMario, 2001)
  • Syncope
    • Commonly encountered in teenagers
    • May have eye-rolling, incontinence, and motor twitching.
    • There are many causes of syncope (don’t forget the pregnancy test!) to consider… like Hair Grooming Syncope.
  • Sandifer Syndrome
    • Gastroesophageal reflux may cause generalized stiffness or posturing.
    • Can have apnea also.
    • Often occurs 20-30 min after a meal.
  • Dystonic Reactions
    • Always look at the medication list!!
  • Migraine Syndromes
    • Basilar Migraine
    • Familial Hemiplegic Migraine
  • Sleep-Related Phenomena
    • Benign sleep myoclonus
    • Periodic sleep jerks
    • Narcolepsy

 

Moral of the Morsel:

NOT ALL THAT SHAKES IS A SEIZURE!

 

References

Luat AF, Kamat D, Sivaswamy L. Paroxysmal nonepileptic events in infancy, childhood, and adolescence. Pediatr Ann. 2015 Feb 1;44(2):e18-23. PMID: 25658214. [PubMed] [Read by QxMD]

Agarwal M1, Fox SM. Pediatric seizures. Emerg Med Clin North Am. 2013 Aug;31(3):733-54. PMID: 23915601. [PubMed] [Read by QxMD]

Singh RK1, Stephens S, Berl MM, Chang T, Brown K, Vezina LG, Gaillard WD. Prospective study of new-onset seizures presenting as status epilepticus in childhood. Neurology. 2010 Feb 23;74(8):636-42. PMID: 20089940. [PubMed] [Read by QxMD]

Obeid M1, Mikati MA. Expanding spectrum of paroxysmal events in children: potential mimickers of epilepsy. Pediatr Neurol. 2007 Nov;37(5):309-16. PMID: 17950415. [PubMed] [Read by QxMD]

DiMario FJ Jr1. Paroxysmal nonepileptic events of childhood. Semin Pediatr Neurol. 2006 Dec;13(4):208-21. PMID: 17178351. [PubMed] [Read by QxMD]

DiMario FJ Jr1. Prospective study of children with cyanotic and pallid breath-holding spells. Pediatrics. 2001 Feb;107(2):265-9. PMID: 11158456. [PubMed] [Read by QxMD]

Hauser WA1. The prevalence and incidence of convulsive disorders in children. Epilepsia. 1994;35 Suppl 2:S1-6. PMID: 8275976. [PubMed] [Read by QxMD]

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Growing Pains

Growing Pain

 

We have discussed previously how working in the Peds ED is like being tasked with finding the rare, life-threatening needle in the haystack of the benign and common.  In order to do this, it requires us to maintain a baseline paranoia helping us to remain ever vigilant.  It also helps to have keen eyesight for subtle red flags. Recently we discussed osteosarcoma, but the child with leg pain will much more likely have Osgood-Schlatter’s Disease or “growing pains.”  It is quite tempting to reflexively diagnose “growing pains” in the young child who is “growing” and has “pain,” but otherwise appears well.  What are the signs that should cause us to pause before we pronounce Growing Pains as the diagnosis?

 

Growing Pains: Not due to growing

  • The cause of growing pains is still debated, but it does not appear to be due to rapid growth. [Mohanta, 2014]
  • Peak age for growing pains is 4-14 years, which is not the peak age for bone growth.
  • The sites of typical pain do not match the areas of maximal growth.

 

Growing Pains: Diagnosis

  • 10-20% of children are affected by growing pains. [Mohanta, 2014]
  • Characteristics of Growing Pains:
    • Occur at night time
      • No daytime symptoms or findings
      • May awaken some at night.
      • May cause crying. [Asadi-Pooya, 2007]
    • Intermittent
      • Occur only once or twice a week
      • Episodes last 30 to 120 min.
      • No consistent pattern
      • Pain free in between episodes
    • Poorly localized
      • No specific joint involvement
        • Usually calf, anterior shin, and or popliteal fossa area.
      • No objective findings on exam
      • No other physical complaints
    • Often occur after having had an active day

 

  • In truth, the diagnosis is one of exclusion! [Asadi-Pooya, 2007]

 

Growing Pains: Consider the Badness!

If growing pains are benign, but are a diagnosis of exclusion, what are some conditions that need to be considered first, before considering growing pains?

 

Growing Pains: Red Flags for Badness

Looking for the dangerous needle in the haystack of benign conditions? Be alert for:

  • Daytime Pain
  • Systemic Symptoms
  • Persistent Pain
  • Localized Pain
  • Only One Limb Involved
  • Joint Involvement
  • Limping
  • Abnormal Exam
  • If any of these are present, you should have a low threshold for investigating further.
  • The diagnosis of growing pains, however, does NOT need laboratory or radiographic testing. [Asadi-Pooya, 2007]

 

Growing Pains: Treatment

Symptomatic treatment… which, again, doesn’t work for osteosarcoma… so be vigilant!

  • Analgesics (NSAIDs)
  • Massage
  • Routine lower extremity muscle stretching twice a day

 

References

Mohanta MP1. Growing pains: practitioners’ dilemma. Indian Pediatr. 2014 May;51(5):379-83. PMID: 24953579. [PubMed] [Read by QxMD]

McCarville MB1. The child with bone pain: malignancies and mimickers. Cancer Imaging. 2009 Oct 2;9 Spec No A:S115-21. PMID: 19965301. [PubMed] [Read by QxMD]

Asadi-Pooya AA1, Bordbar MR. Are laboratory tests necessary in making the diagnosis of limb pains typical for growing pains in children? Pediatr Int. 2007 Dec;49(6):833-5. PMID: 18045281. [PubMed] [Read by QxMD]

The post Growing Pains appeared first on Pediatric EM Morsels.

Growing Pains

Growing Pain

 

We have discussed previously how working in the Peds ED is like being tasked with finding the rare, life-threatening needle in the haystack of the benign and common.  In order to do this, it requires us to maintain a baseline paranoia helping us to remain ever vigilant.  It also helps to have keen eyesight for subtle red flags. Recently we discussed osteosarcoma, but the child with leg pain will much more likely have Osgood-Schlatter’s Disease or “growing pains.”  It is quite tempting to reflexively diagnose “growing pains” in the young child who is “growing” and has “pain,” but otherwise appears well.  What are the signs that should cause us to pause before we pronounce Growing Pains as the diagnosis?

 

Growing Pains: Not due to growing

  • The cause of growing pains is still debated, but it does not appear to be due to rapid growth. [Mohanta, 2014]
  • Peak age for growing pains is 4-14 years, which is not the peak age for bone growth.
  • The sites of typical pain do not match the areas of maximal growth.

 

Growing Pains: Diagnosis

  • 10-20% of children are affected by growing pains. [Mohanta, 2014]
  • Characteristics of Growing Pains:
    • Occur at night time
      • No daytime symptoms or findings
      • May awaken some at night.
      • May cause crying. [Asadi-Pooya, 2007]
    • Intermittent
      • Occur only once or twice a week
      • Episodes last 30 to 120 min.
      • No consistent pattern
      • Pain free in between episodes
    • Poorly localized
      • No specific joint involvement
        • Usually calf, anterior shin, and or popliteal fossa area.
      • No objective findings on exam
      • No other physical complaints
    • Often occur after having had an active day

 

  • In truth, the diagnosis is one of exclusion! [Asadi-Pooya, 2007]

 

Growing Pains: Consider the Badness!

If growing pains are benign, but are a diagnosis of exclusion, what are some conditions that need to be considered first, before considering growing pains?

 

Growing Pains: Red Flags for Badness

Looking for the dangerous needle in the haystack of benign conditions? Be alert for:

  • Daytime Pain
  • Systemic Symptoms
  • Persistent Pain
  • Localized Pain
  • Only One Limb Involved
  • Joint Involvement
  • Limping
  • Abnormal Exam
  • If any of these are present, you should have a low threshold for investigating further.
  • The diagnosis of growing pains, however, does NOT need laboratory or radiographic testing. [Asadi-Pooya, 2007]

 

Growing Pains: Treatment

Symptomatic treatment… which, again, doesn’t work for osteosarcoma… so be vigilant!

  • Analgesics (NSAIDs)
  • Massage
  • Routine lower extremity muscle stretching twice a day

 

References

Mohanta MP1. Growing pains: practitioners’ dilemma. Indian Pediatr. 2014 May;51(5):379-83. PMID: 24953579. [PubMed] [Read by QxMD]

McCarville MB1. The child with bone pain: malignancies and mimickers. Cancer Imaging. 2009 Oct 2;9 Spec No A:S115-21. PMID: 19965301. [PubMed] [Read by QxMD]

Asadi-Pooya AA1, Bordbar MR. Are laboratory tests necessary in making the diagnosis of limb pains typical for growing pains in children? Pediatr Int. 2007 Dec;49(6):833-5. PMID: 18045281. [PubMed] [Read by QxMD]

The post Growing Pains appeared first on Pediatric EM Morsels.