We all know kids love to get objects stuck in areas where no foreign body should be. We have discussed this several times (the Nasal Foreign Body, the Ear Foreign Body, and the Ingested Foreign Body), but the Aspirated Foreign Body is the one that gets our attention the quickest. That is, unless, we missed it at first. Unfortunately, a foreign body in the bronchus may be deceptive and present in a delayed fashion… so, we must be vigilant (as always).
Young Kids are at Risk
- It would seem intuitive that younger kids are at greater risk for aspiration… but why?
- Young kids:
- put random things in their mouths. They like to explore their world… and don’t know what is not edible (hmmm crayons).
- don’t chew their food well. They do not have molar teeth and are prone to have insufficient mastication.
- are easily distracted. It is not a great idea to yell at your sister while stuffing hotdogs in your mouth, but they don’t know that yet.
- don’t protect themselves well. They have relatively high epiglottis and immature swallowing coordination.
Drama is Easy to See, but Subtle can be Dangerous too.
- The aspirated foreign body that leads to respiratory distress won’t be missed by many.
- Unfortunately, an aspirated foreign body may go undiagnosed and this can lead to significant sequelae.
- Persistent febrile illness
- Chronic cough
- Recurrent pneumonia
- Recurrent / persistent “croup”
- Poorly controlled “asthma”
- Lung abscess
- Progressive respiratory distress
- Delayed diagnosis of an aspirated foreign body is associated with increased incidence of complications.
- This is particularly true for any vegetable matter (ex, peanuts), which cause more inflammatory response the longer it is in the body.
Factors Related to Delayed Diagnosis
- Kids 3 years of age and younger are more likely to be diagnosed with foreign body in a delayed fashion.
- These kids are less able to give a reliable history and more at risk (as mentioned above) for aspiration.
Negative Chest X-rays
- Just because the child’s CXR is negative, doesn’t mean that there is not a foreign body!
- It just means your job is more difficult.
- ~50% of known cases of aspiration will have normal chest x-rays.
- Special projection films (decubitus position, exhalation films) can help, but should not be used to completely rule out the condition.
- Normal X-rays should not preclude bronchoscopy in a patient that you have concern for an aspirated foreign body.
- That is taken from the ENT literature — in case you need some support when dealing with consultants.
Care provider negligence
- When no one is supervising, badness can happen (says Captain Obvious).
- One study showed that having No history of a witnessed aspiration episode was associated with delayed diagnosis.
- A lack of a parental report of an aspiration event should not sway you from considering retained foreign body in a child who’s clinical picture suggests it.
Lack of typical symptoms
- With a radio-opaque foreign body, the diagnosis will depend on the history (hopefully someone saw something) and the physical exam.
- Unfortunately, after the initial choking event, the aspirated foreign body may cause little if any symptoms, particularly if it falls to the bronchus.
- The diagnosis is then delayed until symptoms of complications arise.
- Location matters:
- Larynx – typically will have symptoms of obstruction, dysphonia, or hoarseness. If blockage is complete, then can have cyanosis and severe distress / arrest.
- Trachea – similar to larynx in presentation, but can have biphasic stridor, dry cough. Often appear uncomfortable or scared.
- Bronchus – 80-90% of foreign bodies are found in the bronchus. Only 65% will have triad of cough, wheeze, and decreased breath sounds! Can be asymptomatic!
- The absence of symptoms and signs does not rule out the possibility of foreign body if the child has a concerning history of aspiration.
We were not vigilant
- Simply put, we didn’t think about the possibility.
- The diagnosis can be rather difficult, as it may present similar to other conditions:
- Recurrent Croup and Croup are commonly diagnosed instead of Foreign Body.
- Asthma, bronchitis, pneumonia, laryngitis, and URI are other common mis-diagnoses.
Believe the Parents
- Multiple studies have shown that, while a variety of clinical signs may be seen with an aspirated foreign body…
- The most sensitive clinical indicator for an aspiration is there being a “Witnessed Aspiration Episode.”
- Since the physical exam and radiographs may be unenlightening, the parental report of a choking crisis needs to be taken seriously!
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Without question, kids will put the oddest objects into their orifices… and then say that they don’t know how they got there. While this can lead to same comic relief to your otherwise stressful shift, managing a foreign body can also generate its own level of stress. We have great hopes for the offending foreign body being easy to remove as we walk into the room, but then can be derailed by a tenacious monster that refuses to leave and a wailing and flailing child. Those don’t make for any comic relief.
We have discussed many topics with respect to the pediatric foreign body (Aspirated FB, Nasal FB, Button Batteries in the nose, Esophageal Button Batteries), but let us look at the other common entity – the Ear Foreign Body.
- The anatomy of the ear seems simple… an external portion, a tube, and the ear drum. Naturally, it is more complicated than that.
- The External Auditory Meatus can be divided into two portions:
- The lateral third – cartilaginous portion.
- The medial two thirds
- More narrow than the lateral third.
- Lined with a very vascular and highly sensitive thin layer of skin.
- Prone to bleeding with even slight trauma.
- Naturally, the position of the patient can affect your ability to successfully remove the foreign body.
- Make sure that the patient is in a comfortable position for him/her.
- Sitting on a parent’s lap, sideways with the ear in question easily visible will often be the first position of choice.
- This will allow the patient’s legs to be between the parent’s and offer security.
- Also allows for the torso to be supported and arms kept safely out of the way.
- Teaching the family member how to do this can save everyone some time and sweat.
- Equally important is to make sure that the patient is in a position that allows you to be comfortable.
- You may be very good a yoga, but there is no need to demonstrate your skills while attempting to remove a foreign body.
- Anticipate that this will not be easy and may take a few minutes… so position your tools within easy reach.
- The position of the Foreign Body is also very important.
- Foreign bodies that are in the medial two thirds of the canal are much more problematic and more difficult to remove.
- In this area, the patient will be more uncomfortable and less likely to hold still.
- You are also more apt to cause trauma (to the canal or TB) with foreign bodies that are in this region.
- You need to have optimal circumstances and be very careful with foreign bodies in the medial two thirds of the canal.
Pain Management Matters
- Even the most cooperative child will loose the ability to calmly sit still as you scrap and claw at a foreign body, especially one in the medial two thirds of the canal.
- Be kind. Use some pain medications when appropriate.
- A common trick is to use topic lidocaine.
- It is important to first make sure that there is no perforation of the TM before pouring any fluids into the canal.
- This is very helpful with insects that are entrapped, as it will drown the insect and make everyone’s job easier.
- Ketamine is great too!
- Ok, so this isn’t something to pull out right away, but occasionally, the child with an ear foreign body will need procedural sedation.
- Short acting agents would be ideal (propofol). ENT would likely go to the OR for anesthetic gas.
The Object Matters
- A endless variety of foreign bodies have been removed from ears (from cotton to cheese; from bead to popcorn kernel; from eraser to putty).
- There are characteristics that can make the Foreign Body more difficult to deal with:
- Vegetable Matter (food, beans, etc)
- Do not use irrigation as this may cause the foreign body to swell and become more entrapped.
- Button batteries
- Cause liquefaction necrosis and need to be removed promptly.
- Sharp objects
- If not removed very carefully, may cause more injury and damage during the removal.
- Smooth, round objects
- Difficult to grasp.
- Especially challenging when they are in the medial 2/3 of the canal.
The Tool Matters
- Having a wide array of tools can help you adapt to the various challenges that each foreign body offers.
- These can come in handy:
- Forceps (alligator and Hartman)
- Frazier suction
- Cerumen loop
- Right-angle ball hook
- Schuknecht foreign body remover
- Aural irrigation devise
- Can be made using a 60 ml syringe and an 18 gauge angiocath.
- Ensure that the water is body temperature (so you don’t make the child vertiginous).
- Otomicroscope would be quite handy.
Knowing Your Limits Matters
- Occasionally, you won’t be successful.
- When should you refer to the ENT doctors?
- Unable to remove after multiple attempts.
- Multiple attempts increases risk of complications, which can lead to other long term issues.
- Tightly wedged objects
- Objects resting against the TM
- Sharp objects
- Button batteries
- These, however, cannot wait until the next day in the ENT office.
- If you can’t get it out, then the ENT needs to come in to get it out.
- After you have successfully removed the Foreign Body, your job is not done.
- Ensure that all parts have been removed.
- Especially important for insects.
- Residual barbed insect legs can lead to inflammation and damage.
- Ensure that no other orifice has a Foreign Body.
- Kids are tricky.
- Check their other ear and the nostrils!!
- Important to educate the patient and family about the hazard of the foreign body (this time it was the ear, next time it might be the airway).
- If there was some trauma to the canal (laceration, inflammation), then prescribe antibiotic otic drops and give water precautions. Follow-up examination will be important.
The post Ear Foreign Body appeared first on Pediatric EM Morsels.
Once again, a common theme of the Morsels is a need for vigilance. Unfortunately, sometimes those seemingly straight forward cases of vomiting in fact are due to an Inborn Error of Metabolism and it requires our vigilance to make the diagnosis. Many of us, however, also abide by the rule that “if it looks like a duck, walks like a duck, and quacks like a duck, then it is a duck.” So what should we make of the patient who presents with what looks and sounds like croup, but it is recurrent?
- We have dealt with the common issue of Croup previously.
- Croup caused by viral infection effecting the larynx, trachea, and/or bronchi.
- Characterized by barking cough and stridor.
- Can be associated with respiratory distress.
- Typically seen during the Fall and Winter months.
Croup vs Recurrent Croup
- Viral Croup is does not usually occur more than once (or twice) in a year in a otherwise healthy child.
- Croup like symptoms that occur more frequently (>2 a year) have been called “Recurrent Croup.”
- Essentially, recurrent croup is not due to a viral etiology and should be considered a RED FLAG for another condition.
- Recurrent croup can be the presentation of underlying intrinsic or extrinsic airway narrowing.
- Usually 1-2 episodes per year
- Ages: 6 mos – 3 years with peak at 2 years
- Usually short in duration (1-2 days)
- Standard therapy usually treats the symptoms
- > 2 episodes per year
- Any age. Be suspicious of croup in a child < 6 months or > 3 years of age.
- Relapsing and remitting course. Can persist over weeks.
- Some or no response to standard therapy for croup.
Recurrent Croup – Some Causes to Consider
- Subglottic stenosis
- Traumatic – from prior intubation
- Subglottic cysts
- Subglottic hemangioma
- Look for hemangiomas on the child’s face, particularly the beard distribution.
- Recurrent respiratory papillomatosis
- Vocal cord paralysis
- Tracheoesophageal fistula
- Foreign Bodies
- Congenital cardiovascular abnormality
- Gastroesophageal reflux
- Asthma / Allergy
- Mediastinal mass
Timing of Stridor
- Not everything works as planned… but listening to the timing of the stridor can help point toward potential cause.
- Supraglottic problem
- Laryngomalacia is an example.
- Tracheal pathology
- Ex, compression from aberrant vascular structure.
- Glottic or Subglottic problem
- Subglottic stenosis or vocal cord paralysis are examples.
The Moral of the Morsel
- If you are taking care of a child who is presenting with what appears to be croup, but this marks the 3rd or greater occurrence of it, then you are dealing with Recurrent Croup.
- Recurrent Croup should be considered a RED FLAG for something that isn’t as simple as a viral illness (perhaps one of those needles of serious disease in the haystack of coughing).
- Anatomic abnormalities have been reported in a significant proportion of patients with recurrent croup.
- Have a lower threshold for checking plain films for possible foreign bodies.
- Most, if not all, of these patients will require bronchoscopy by ENT to rule out anatomic abnormalities.
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Something that is certainly unique about the practice of emergency medicine is the approach to problems from the “worst first” perspective. Now, generally, I would consider myself as someone who minimizes testing and prefers to spend a few extra minutes getting a solid history and performing a detailed exam. Through this approach, I find that I am able to contemplate the “Big, Bad, and Ugly” issues often without ordering a million tests (don’t get me started about the white count!).
One group, however, often requires me to accept my limitations and operate on the more conservative side of caution. The neonate may be super cute, but is also extremely tricky! We have discussed numerous neonatal topics previously (there is an entire category for them — Hypothermia in a Neonate, Interosseous Access, No Need for Atropine, Neonatal Analgesia, and Necrotizing Enterocolitis to name a few). We have also discussed ALTE (Apparent Life Threatening Events) previously. While we have noted that the evaluation of an ALTE is best determined by a thorough history and physical, the neonate warrants a slightly more conservative approach.
- ALTE is NOT a diagnosis. It is a collection of symptoms.
- ALTE is defined as an episode that is “frightening” to the care provider and is characterized by some combination of pathologic apnea, color change, change in muscle tone, choking, or gagging.
- Pathologic Apnea = apnea associated with cyanosis, pallor, hypotonia, or bradycardia (which would only be known if on a monitor really) OR apnea of greater than 20 seconds in duration (which is a really long time for a parent to count when their kid is not breathing).
- The rather broad “definition” of ALTE leads to some difficulty in researching it and in interpreting the results of the research.
ALTE Differential Diagnosis is VAST
- Since ALTE represents a collection of symptoms, numerous conditions can be responsible.
- A thorough H+P often points toward a diagnosis and directs the work-up.
- GERD, Seizures, and Lower Respiratory Tract Infections are the most common diagnoses found after evaluation of ALTE.
- Many ominous conditions have been associated with ALTE as well:
- Serious Bacterial Infections
- Congenital Heart Disease
- Inborn Errors of Metabolism
- Ondine’s Curse (Congenital Central Hypoventilation Syndrome)
- Many times no diagnosis is found (idiopathic ALTE).
- In general, it is known that broad and expansive testing is often of limited value.
- It is best to tailor the evaluation based on a thorough history and physical exam.
- Currently there are investigations to better determine who benefits from admission; however, there is currently no validated study that reliably identifies this group of children.
ALTE in the NEONATE
- Neonates are tough to figure out!
- They can’t tell you what really happened.
- They’re repertoire to demonstrate any illness is limited.
- Neonates who are seriously ill may only demonstrate that fact by being hypothermic.
- We all know that the “well appearing” neonate can still be hiding serious illness.
- Your physical exam is less helpful in determining an etiology of the event.
- You cannot rely on finding meningismus.
- Even paradoxical irritability can be difficult to discern in the neonate.
- Neonates often have a different breathing pattern that can alarm care providers.
- Periodic Breathing is a normal variation of breathing.
- It is characterized by pauses of breathing for less than 20 seconds (more typically less than 10 seconds).
- Often followed by some increased respiratory rate.
- There is no change in color or tone.
- This is NOT pathologic apnea, but often catches the attention of the care giver.
- Neonates that do Weird Things Make Me Nervous!
- Yes, the literature would argue that the overall incidence of serious bacterial infections in all cases of ALTE is low.
- Meningitis 0-1.6%
- Bacteremia 0-2.5%
- UTI 0-7.6%
- Respiratory Tract Infection 0-10%
- If the story fits neither a simple gagging episode with feeding nor periodic breathing, then I have to ask myself why did this neonate have Pathologic Apnea.
- While the numbers may not favor a serious bacterial infection… I have a hard time proving that to myself in a neonate.
- Perhaps it was a seizure… hmmm… why did the neonate have a seizure… once again infection is high on that list.
- Therefore, I still vote for the “worst first” approach and look to have someone tell me in two days that the neonate did not have a serious bacterial infection.
- In short, these neonates I perform a full sepsis work-up on.
- ALTE in Neonate = Full Sepsis Work-up!
- If the story is a little odd… you know the one where you just can’t seem to get your hands around what happened.
- Then I would favor a cautious, but reasonable approach.
- Sepsis screen with Urine studies and Urine Culture and admission for close observation.
- Naturally, a conversation with the admitting team to develop a joint plan is always appreciated.
- Aside from serious bacterial infections… don’t forget other badness in neonates!!
- Inborn Errors of Metabolism
- Congenital Heart Disease
So, in the end, when evaluating the neonate for an ALTE, don’t just resort to the common approach of “that’s an easy admission” and admit for “obs.” Rather, be a little fearful… and start looking for those needles in the haystack of disease.
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Ascending paralysis naturally evokes concern for Guillain-Barre syndrome, but one entity that should be on your differential and requires special action is Tick Paralysis. Let’s take a minute to refresh our memories about this interesting and important condition.
- Prodrome con be seen and generally lasts < 24 hours.
- Restlessness and Irritability
- Fever is seldom present
- Acute symmetric ascending flaccid paralysis.
- Unsteady gait can be the initial finding.
- Usually develops 2-6 days after tick attachment (so consider where the patient may have been over the past several days).
- Decreased deep tendon reflexes.
- Progressive Ascending Weakness if the tick continues to feed.
- Can see weakness of upper extremities.
- Cranial nerve involvement can also be seen – drooling, dysphagia, dysphonia, and facial weakness.
- Opthalmoplegia and pupillary dilation have been reported.
- Atypical presentations have noted focal weakness or isolated facial weakness or isolated cerebellar ataxia.
- Involvement of the respiratory muscles can occur.
- Without supportive care, can lead to death.
- Historically, 6% of patients with tick paralysis died.
- Girls with long hair
- < 8 years of age
- Spring and Summer months
- Australia (Ixodes holyclus)
- North America
- Rocky Mountain region, Pacific Northwest, Southwest Canada (Dermacentor andersoni)
- Southeast region (Dermacentor variabilis)
- The paralysis is caused by a neurotoxin that is produced in the tick’s salivary glands.
- The exact mechanism is not fully characterized.
- Believed to decrease the presynaptic acetylcholine release at the neuromuscular junction.
- May function similar to botulinum toxin.
Other Diagnoses Often Confused with Tick Paralysis
Naturally, evaluating a patient who presents with acute ascending weakness with hyporeflexia will generate concern for the following, and Tick Paralysis is important to consider as well. When you are considering any of these conditions, you should look closely for any attached ticks and ask about potential exposure. 22% of cases in the USA were initially misdiagnosed and the mean time for correct diagnosis was >2 days.
- Guillain-Barre Syndrome
- Myasthenia gravis
- Lambert-Eaton syndrome
- Transverse myelitis
- Periodic paralysis
- Spinal Cord Compression
- Heavy metal poisoning
- Organophosphate poisoning
- Tick paralysis is diagnosed based on clinical findings concurrent with discovering an engorged tick.
- There is not a specific test that is advocated to confirm the diagnosis.
- Laboratory studies and imaging is often done to rule out other entities.
- This is why considering Tick Paralysis and performing a Tick Check is important.
- There are known cases of MRIs being done for the evaluation of the weakness only to demonstrate an engorged tick (kinda creepy really– but also a waste of money to obtain an MRI of a Tick — ticks don’t have insurance).
- CSF studies are normal.
- Simple – remove the tick
- With Dermacentor ticks, the symptoms tend to improve shortly after removal.
- With Ixodes ticks, the symptoms may persist for 1 – 2 days after removal.
- Some cases of prolonged symptoms have been noted in Australia.
Moral of the Morsel
Keep Tick Paralysis on your DDx when evaluating a patient with acute weakness and look closely for any attached ticks, as this may dramatically alter your potentially expensive and expansive evaluation.
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We obtain ECGs for a number of reasons in the ED, but in the pediatric ED, we often obtain them in the child who presents with a complaint related to syncope. We have discussed syncope issues previously (Syncope, Hair-combing syncope, SVT, Heat Related Illness, and Prolonged QTc and Submersion Injuries). Since syncope is commonly seen, let us make sure we know what to do when we see one of the potential items we are looking for on that 12-Lead ECG: Prolonged QTc.
- The QT segment:
- Is the duration of the segment from the start of the Q wave to the END of the T wave.
- It represents the period of ventricular depolarization and repolarization.
- It is inversely proportional to the heart rate (shorter with faster heart rates).
- The QTc:
- Represents the “corrected” value that would be seen with a heart rate of 60bpm.
- If heart rate is between 60 and 100 bpm, you can use the actual QT measurement.
- Allows for comparison and detection of risk for dysrhythmias.
- Multiple formulas used to determine the QTc…
- None are perfect and I’m not smart enough to recommend one over the other.
- I generally use what the computer says– otherwise I ignore the computer reading.
- The QTc Values:
- Normal for men = 350ms – 440ms
- Normal for women and children = 350ms – 460ms
- Risk for dysrhythmias is increased when >500ms
Prolonged QTc Causes
- Too many to actually list here, but some commonly used Rx in Peds are:
- Macrolides (Erythromycin, Clarithromycin, Azithromycin)
- Fluoroquinolones (Levofloxacin, Gatifloxacin, Ciprofloxacin)
- Antifungals -(Fluconazole, Itraconazole, Voriconazole)
- Bactrim (another reason not to use bactrim)
- Antipsychotics (Amitriptyline, Desipramine, Imipramine, Sertraline)
- Sedatives (Chloral hydrate)
- ONDANSETRON (I know we have discussed it’s value, but nothing is perfect)
- Electrolyte Issues
- Congenital Long QT Syndrome
- Cardiac ischemia
- Increased ICP
Why We Care
- Prolonged QTc can precipitate Torsade de Pointes.
- Your evaluation of the syncope patient will include this as a possible etiology of poor cerebral perfusion.
- Many times you will find a “bordeline” QTc prolongation (460 – 500 ms) and you will need to deal with that issue.
- One study showed that 1/3 of pediatric patients with borderline QTc had normalization on follow-up.
- Be careful not to get the families too crazy about the borderline QTc… but do ensure follow-up.
What to Do
- If ventricular ectopy is present (or Torsade de Pointes) – treat with Magnesium 25-50mg/kg.
- If noted on ECG, but stable, look for causes (check lytes and go over each drug they are on).
- Always be mindful of the medications you prescribe!
- Stop any potential offending agents!
- Ask family about any family history of sudden death or unexplained drowning.
- Ensure appropriate follow-up.
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