Pediatric infectious diseases have been a common topic for the PedEMMorsels and rightfully so as kids love to collect numerous viral and bacterial infections (ex, Measles, Flu, Mumps, Omphalitis). With that being said, pneumonia is often the topic of conversation in the Peds ED and, thus, deserves special attention. We have discussed pneumonia several times previously (ex, Pneumonia Detective, Round Pneumonia, Penicillin for Pneumonia, and CAP), but recently our friends at the Section on Emergency Medicine at the AAP published a easy to follow guide to Community Acquired Pneumonia (displayed below). Let is take another moment to ensure we are up to date with current recommendations for Pediatric Pneumonia.
Pediatric Pneumonia: Basics
- We see a lot of it – accounts for >500,000 ED visits annually!
- Accounts for ~7% of pediatric admissions.
- Streptococcus pneumoniae is the most common bacterial cause of community acquired pneumonia in kids.
- Narrow spectrum beta-lactam antibiotics are still very effective against S. pneumoniae.
- A significant amount of patients (even after published recommendations) continue to receive unnecessary broad spectrum antibiotics as initial therapy! [Ross, 2014]
AAP Pediatric Pneumonia Algorithm 2017
Moral of the Morsel
- Penicillin works well! Most children, even ones who require hospitalization, will benefit from a narrow spectrum penicillin.
- Look for an effusion! The presence of an effusion makes it a more complicated pneumonia and warrants more careful consideration.
- No blood required! The mild and most of the moderate pneumonias will not benefit from extensive blood testing.
Bradley JS1, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, Kaplan SL, Mace SE, McCracken GH Jr, Moore MR, St Peter SD, Stockwell JA, Swanson JT; Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America.
Clin Infect Dis. 2011 Oct;53(7):617-30. PMID: 21890766
. [PubMed] [Read by QxMD]
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Children are often more susceptible to environmental exposures and injuries. We have previously discussed injuries related to submersions, heat-related illness and hyperthermia, thermal burn, and hypothermia. Essentially, no matter what environment a child is in, there is usually a potential hazard nearby. One of the most ubiquitous potential hazards is electricity. Now let us take a minute to digest a morsel of information about Electrical Injury.
Electrical Injury: Voltage Matters
- Electrical injuries and burns are a worldwide problem.
- Most commonly affects small children and teenagers (as well as adults). [Glatstein, 2013]
- Small children often encounter household electricity – so low voltage. [Arasli Yilmaz, 2015]
- Teenagers (particularly males with poor decision making capacity due to high testosterone to common sense ratio) may expose themselves to high voltage outside of the home. [Arasli Yilmaz, 2015; Celik, 2004]
- Tissue damage is dependent upon voltage, type of current, amperage, tissue resistance, and time of exposure.
- In general, exposure to high voltage is associated with higher morbidity and mortality. [Arasli Yilmaz, 2015]
- Low Voltage refers to electricity up to 1,000 Volts
- Most frequent cause of electric burns.
- Most often leads to minor injury and no serious complications.
- High Voltage refers to > 1,000 Volts
- Associated with greater risk of direct injuries from electrical charge.
- Also associated with greater risk for related polytrauma.
- May cause muscle tetany leading to patient’s inability to let go of electrical source.
Electrical Injury: Injuries
- Injuries can range from minor to life-threatening.
- All tissues can be affected by the electric current passing through them. [Arasli Yilmaz, 2015]
- Cardiac arrest can occur due to exposure to high voltage
- Cardiac arrhythmia
- Diaphragm muscle paralysis
- Cardiac conduction abnormalities
- ST changes, heart blocks, prolonged QTc, SVT, and a-fib.
- May evolve over time due to necrosis of the myocardium cardiac nodes, conduction pathways, or coronary arteries. [Arasli Yilmaz, 2015]
- Tissue burn
- Unlike thermal burns, visible appearance of necrosis may be misleading.
- May only have small area involved on surface, but extensive injury exists.
- Usually do not require skin-grafting: commonly partial thickness or less.[Alemayehu, 2014]
- Compartment Syndrome from edema caused by local tissue injury.
- Hepatic injury
- Delayed thrombosis or necrosis can occur.
- Delayed aneurysm formation or hemorrhage may also happen.
- Associated Injuries
- Trauma related injuries from fall
- Rhabdomyolysis from tissue destruction or compartment syndrome
Electric Injury: Evaluation
- Low Voltage Exposure
- Most often have only minor injuries (ex, superficial 1st degree burn).
- If no concerning features (ex, prolonged exposure, wet skin, concerning medical history), do not benefit from extensive testing or hospitalization. [Arasli Yilmaz, 2015; Zubair, 1997]
- ECGs are not likely to find any abnormalities and may not need to be mandatory. [Glatstein, 2013]
- Personally, I have low threshold for ECG and short period of observation in ED.
- High Voltage Exposure
- ECG should be obtained.
- Continuous cardiac monitoring is recommended if there is an abnormal ECG, concerning past medical history, or other concerning features (ex, prolonged exposure, wet skin, loss of consciousness).
- Basic laboratory studies should include creatine kinase levels, renal function, LFTs, and urinalysis. [Arasli Yilmaz, 2015]
- Need a thorough trauma evaluation, including FAST and Imaging as needed.
- Wounds should be covered with sterile gauze and antibiotic ointment (unless you are transferring to a Burn Center, in which case discuss with accepting facility as they will often prefer only sterile gauze until they are able to see the wounds).
- Indications to transfer to tertiary Burn Center are similar to thermal burns. [Glatstein, 2013]
- Admission is encouraged for:
- High voltage exposure
- Presence of entry and exit wounds
- Neurologic instability
- Cardiovascular instability
- Large area of burn
- Burns that prevent adequate oral hydration
Electric Injury: Oral Burns
- One unique entity that affects children (particularly < 5 years of age) is electrical burns due to bitting a live wire from an electric appliance or mouthing the female end of a connected extension cord. [Umstattd, 2016]
- Injury pattern consists of burn to the oral commissure.
- Can lead to poor outcomes, both functionally and aesthetically.
- The low voltage nature of these injuries typically spares the deep tissues.
- Can injury local labial artery and develop significant bleeding, even in a delayed fashion when scab sloughs off. [Zubair, 1997]
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While most often the pediatric patient’s past medical history is rather concise, there are children whose medical complexity rivals any of their adult counterparts. These children often present with various “technologic gear” (ex, VP Shunt, Baclofen Pump, PICC lines) and one of the most commonly encountered medical device is the gastrostomy tube. Let us take a moment to review the potential Gastrostomy Tube Complications.
Gastrostomy Tube: Basics
- Gastrostomy tubes were first developed in the late 19th century! [McSweeney, 2016]
- Originally, they were placed via open surgical procedures.
- Percutaneous Endoscopic Gastrostomy (PEG) tubes have been used since 1980.
- Gastrostomy tubes can also be placed via laparoscopic procedures. [McSweeney, 2016]
- Gastrostomy tract takes several weeks to mature.
- The mature tract occurs when the layers of abdominal wall, peritoneum, and stomach adhere to each other.
- Early manipulation of the tract runs the risk of disruption of the tract and creating false tract.
- The time it actually takes for a tract to mature is variable and based on the individual.
- An interval of 3 months is usually consider sufficient. [Willwerth, 2001]
- Patients with poor wound healing (ex, malnourished) or who are on chemotherapeutics may require longer times for tract maturation. [ Willwerth, 2001]
- G-tubes have been safely used, but can be associated with complications.
- Individual articles often define complications differently, and thus rates vary between 4% to ~50%. [McSweeney, 2016]
- Patients with more/severe comorbidities (ex, VP Shunt) have greater risk for complications. [Goldin, 2016; McSweeney, 2015]
- Most complications occur within the 1st year of placement. [McSweeney, 2016]
Gastrostomy Tube: PEG vs Button
- PEG tubes can be used indefinitely, but for comfort and cosmetic reasons may be exchanged with a skin-level “button” gastrostomy tube.
- The skin-level g-tube has the advantage of being low-profile and being more inconspicuous, but require extension tubing and for children who require continuous enteral feeds, this can be problematic.
- Exchanging from PEG tube can lead to complications with disruption of the ostomy tract.
- Skin-level tubes are usually not placed until the tract has had a chance to mature (~3 months). [Willwerth, 2001]
- When exchanged for the first time, often it is recommended that position be confirmed via fluoroscopic imaging. [McSweeney, 2016]
- Some advocate for another endoscopic procedure to exchange the tubes.
Gastrostomy Tube: Complications
- Disruption of Ostomy Tract
- Peritonitis and Septicemia
- Gastric Outlet Obstruction
- From migration of the PEG tube distal ballon to the pylorus or beyond.
- From overfilling balloon. [Showalter, 2012]
- May also lead to bowel perforation. [Saavedra, 2009]
- Dislodged G-tube
- This is the most common complaint associated with g-tube evaluations in the ED. [Saavedra, 2009]
- Most are replaced by ED physicians without consultation or surgeons. [Saavedra, 2009]
- G-tube Malfunction
- May be unclogged with warm water or diet soda infusion. [Willwerth, 2001]
- Leaky G-tube
- Rupture Ballon
- Local Ostomy Site Infection / Irritation
Gastrostomy Tube: Dislodgment Management
- Is the tract mature?
- As mentioned above, patient factors may influence the maturity of the tract.
- Tracts that have been present for >3 months are likely mature.
- If a skin-level g-tube was most recently in place, it likely is a mature tract.
- If not mature, or it is unclear, consult pediatric surgery (or GI) immediately.
- Timely replacement of a dislodged tube is critical. [Willwerth, 2001]
- The tract will begin to become stenotic within hours.
- Families are often given replacement tubes and educated on how to replace tubes.
- Know the equipment.
- There are several types of skin-level gastrostomy tubes: [Willwerth, 2001]
- Ballon-type (i.e., MIC KEY) – ballon is inflated with sterile water
- Mushroom-shaped (i.e., Bard) – requires stylet for placement
- Collapsible wings (i.e. Malecot) – requires stylet for placement
- Test device integrity PRIOR to inserting it.
- Make sure inflated balloon does not have a leak.
- Ensure removal of stylet appropriately deploys the anchoring device.
- Replacement with the same length and calibre tube is ideal, but…
- Anticipate tract stenosis.
- Obtain several sizes of g-tubes, as well as foleys, just in case.
- A set of surgical dilators (ex, Hager dilators) can be very helpful!
- Inserting progressively larger dilators or g-tubes/foleys can help reestablish the previous size of the ostomy to accommodate the prior g-tube calibre. [Willwerth, 2001]
- Be gentle.
- Replacement should be painless, but occasionally is anxiety provoking or even uncomfortable.
- Applying viscous lidocaine to the tract can assist with placement.
- Apply lubricant to both ostomy site and g-tube.
- Gentle, but steady pressure is all that is needed to slide the g-tube into place.
- Apply pressure perpendicularly to the abdominal wall.
- When removing the stylet, or inflating the balloon, there should not be pain.
- If there is, the anchoring device may be out of position and within the tract.
- Deployment of the anchor in this case may lead to complications.
- Confirm placement.
- Aspiration of stomach contents from the g-tube and listening for borborygmi while instilling 10-15 ml of air is often all that is required. [Showalter, 2012; Willwerth, 2001]
- If insertion was difficult and/or location is uncertain, confirmation can be done with dye-study (contrast infused through g-tube and AXR obtained in 2 planes) or under fluoroscopy.
Moral of the Morsel
- Be cautious. If the gastrostomy has been in place less than 3 months, consult the clinician who placed it.
- Be proactive. Do not let the dislodged g-tube sit in triage or waiting room. Being proactive may save a lot of time and energy by avoiding stenosis of the tract.
- Be gentle. Replacement of g-tubes should not be painful, but may be associated with anxiety. Some children do better with topical lidocaine to help with placement.
- Be certain. Confirm placement of the tube. Most can be confirmed with simple bedside assessment, but more complicated patients, ones with “younger” tracts, or ones that were more challenging to replace may benefit from imaging.
- Be eloquent. Ok… you don’t have to be eloquent… but you do need to document your method of insert and confirmation of placement of the g-tube (this is often forgotten – [Saavedra, 2009])!
Goldin AB1, Heiss KF2, Hall M3, Rothstein DH4, Minneci PC5, Blakely ML6, Browne M7, Raval MV2, Shah SS8, Rangel SJ9, Snyder CL10, Vinocur CD11, Berman L11, Cooper JN5, Arca MJ12. Emergency Department Visits and Readmissions among Children after Gastrostomy Tube Placement.
J Pediatr. 2016 Jul;174:139-145. PMID: 27079966
. [PubMed] [Read by QxMD]
Sulkowski JP1,2, De Roo AC1, Nielsen J1,2, Ambeba E1, Cooper JN1, Hogan MJ3, Erdman S4, Deans KJ1,2, Minneci PC1,2, Kenney B5,6. A comparison of pediatric gastrostomy tube placement techniques.
Pediatr Surg Int. 2016 Mar;32(3):269-75. PMID: 26686696
. [PubMed] [Read by QxMD]
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Recently, @EMHighAK (Alex Koyfman) asked about any “teaching points” with respect to Pediatric DKA and Cerebral Edema. In addition to referencing an oldie, but a goodie morsel on Cerebral Edema, I also mentioned that we should all be careful not to attribute all ketonuria in vomiting kids to “starvation ketosis.” That got me to thinking about other potential diabetes related urine pitfalls. What about the child with polyuria but no glucosuria? Is that reassuring and do I quickly assume that the child is just super-hydrated? Let us take a minute to recall that there is another diabetes to consider: Diabetes Insipidus.
Diabetes Insipidus: What’s in a name?
- “Diabetes,” etymologically, has origins in words that mean “to pass through” and was used to describe excessive passage of urine (polyuria).
- “Mellitus” has origins from words that mean honey and/or sweetness.
- “Insipidus” stems from words that meant lacking flavor or taste.
- So to differentiate between the two, all we have to do is taste the urine. Simple.
- This was how physicians of antiquity would evaluate the urine. (Delicious!)
- Ok… I don’t advise this… and I’m pretty sure there are some hospital regulations that make that practice a reason to terminate your employment.
- I am glad we have replaced human tongues with urine dipsticks for this!
Diabetes Insipidus: Basics
- Diabetes Insipidus = the inability to concentrate urine
- Can be due to:
- Central CNS process – vasopressin deficiency
- Any process that impairs production and release of vasopressin can lead to diabetes insipidus. [Dabrowski, 2016]
- Central Diabetes Insipidus (DI) is more common than Nephrogenic DI
- Nephrogenic process – vasopressin resistance
- Vasopressin production is adequate.
- Vasopressin should activate the V2 receptor in the collecting duct, inserting aquaporin 2 channels allowing free water to be reabsorbed.
- Errors in the V2 receptor or aquaporin 2 channels will lead to diabetes insipidus. [Dabrowski, 2016]
- Diabetes Insipidus is rare, but can be associated with some common conditions.
- Prevalence = 1:25,000
- ~90% of cases are acquired, rather than inherited.
- Some common acquired causes: [Dabrowski, 2016]
- Intracranial tumors (ex, Craniopharyngioma, Optic Glioma)
- Trauma (~18% of severe traumatic brain injury develop DI) [ Alharfi, 2013]
- CNS Infections (ex, Meningococcal, Cryptococcal, Toxoplasmosis)
- Hypoxic-Ischemic Injury
- Postpartum Hemorrhage (Sheehan Syndrome)
- Infiltrative (ex, Sarcoidosis, Leukemia)
- Primary Renal Disease
- Medications (lead to Nephrogenic DI mostly):
- Lithium (most common culprit)
- Antimicrobials (ex, amphotericin B)
- Antineoplastic agents (ex, cisplatin, vinblastine)
- Ketamine (ok, only case reports of this… but just be aware) [Hatab, 2014]
Diabetes Insipidus: Presentation
- Extreme thirst, particularly with a preference for cold water. [Dabrowski, 2016; Haddad, 2016]
- Intense water seeking behaviors.
- Urine output > 2 L/m^2/Day
- Urine output > 150 ml/kg/Day (neonates); 100-110 ml/kg/Day (up to 2yrs); 40-50 ml/kg/Day (older kids)
- New onset enuresis in previously toilet-trained child? Think DM or DI.
- Additional signs/symptoms due to intracranial processes: [Dabrowski, 2016]
- Growth retardation
- Infants may present in first few weeks of life with growth failure. [Ranadive, 2011]
- Fever of unknown origin
- Emesis (hmm… emesis and polyuria… sounds like DKA… but it isn’t… be vigilant)
- Visual field cuts
Diabetes Insipidus: Evaluation
- Chemistry panel for sodium, potassium, glucose, BUN, and Calcium.
- Normal glucose? Not likely diabetes mellitus related polyuria.
- Hypercalcemia and Hypokalemia can induced nephrogenic DI.
- Urinalysis for urine specific gravity and urine glucose
- Serum osmolality and Urine Osmolality [Dabrowski, 2016]
- Urine studies are more reliable on first morning void.
- Radom Serum Osm > 300 mOsm/kg at the same time Random Urine Osm < 600 mOsm/kg is indicative of diabetes insipidus. [Dabrowski, 2016]
- Water deprivation testing is used to confirm diagnosis (needs to be done as an inpatient for close monitoring). [Dabrowski, 2016]
- Neuro imaging (Brain MRI) is often performed after diagnosis is made to evaluate the pituitary.
Diabetes Insipidus: Management
- Management of children with diabetes insipidus can be very complicated and requires constant supervision and monitoring.
- Therapies can place young children at risk of water intoxication and hyponatremia.
- Not treating young children places them at risk of dehydration and hypernatremia.
- Infants and young children are particularly challenging to manage. [Dabrowski, 2016]
- Don’t have free and easy access to water.
- < 2 months of age, normal kidneys are not able to maximally concentrate urine.
- Breast milk has a lower solute load than standard formulas.
- Free access to water!
- Children with mild diabetes insipidus can be treated with only increasing fluids.
- With more significant cases, the amount of fluid required can lead to complications (ex, hydronephrosis), so medications are required.
- Synthetic vasopressin / DDAVP
- Mainstay of treatment for Central DI
- Will not affect Nephrogenic DI
- Thiazide diuretics
- Induce natriuresis and subsequent volume contraction
- Volume contraction leads to increased water and sodium reabsorption in proximal tubule.
- Safer alternative for infants than DDAVP.
- Can be used for both Central and Nephrogenic DI.
- Indomethacin or Amiloride
- Used in combination with Thiazide Diuretic for Nephrogenic DI
Moral of the Morsel
- Polyuria and Polydipsia is concerning for diabetes! Just don’t forget that it may be Insipidus and not Mellitus.
- Remain vigilant and fight the urge to have early closure on a potential diagnosis.
- Remember the associated acquired conditions – polyuria after closed head injury? – consider DI!
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We have discussed several overuse and sports related injuries (ex, Little League Shoulder, Osgood Schlatter’s, Patellofemoral Pain) and how children’s immature skeletal structure makes their injuries unique (ex, Ankle Injury, Lateral Condyle Fx, Supracondylar Fx). There is another unique pediatric apophyseal injury that deserves attention and results in a pelvic fracture. Let us take a minute to review Pelvic Avulsion Fractures.
Pelvic Avulsion Fracture: Basics
- Relatively rare
- Occurs primarily in adolescent atletes [Schuett, 2015; White, 2002]
- Adolescents compete in strenuous activities.
- Hormonal changes with puberty increase muscle strength.
- Pelvic apophyseal centers don’t ossify until adolescence.
- Weaker apophyseal cartilage may fail under stress and lead to avulsion fracture.
- Commonly associated sports/activities: [Schuett, 2015; Rossi, 2001; White, 2002]
- Sprinting (ex, track, soccer, baseball, football)
- Jumping (ex, hurdles)
- Kicking (ex, soccer)
- Twisting (ex, swinging bat)
- Gymnastics, especially floor exercise
Pelvic Avulsion Fracture: Anatomy Matters
- Specific activities are associated with particular avulsion fractures based on anatomy. [White, 2002]
- Timing of the closure of the various ossification centers also influences when specific injuries occur. [Schuett, 2015]
- Anterior Superior Iliac Spine (ASIS)
- Origin of the sartorius muscle anteriorly [White, 2002]
- Sartorius muscle pulls ASIS anteriorly and inferiorly
- Usually avulses a small fracture fragment.
- Running activities are most commonly related to this injury pattern.
- Origin of the tensor fascia lata laterally and posteriorly [White, 2002]
- The tensor fascia lata avulses a larger fragment in the lateral direction.
- Twisting activities (ex, swinging bat) are most commonly related to this injury pattern.
- Anterior Inferior Iliac Spine (AIIS)
- Origin of the rectus femoris [White, 2002]
- Often seen when leg is kicked powerfully (ex, soccer, sprinting)
- More likely to lead to chronic pain. [Schuett, 2015]
- Ischial Tuberosity
- Origin of the hamstring muscles [White, 2002]
- Avulsion of the ischial tuberosity occurs during hip extension (ex, gymnastic floor routine, sprinting, hurdling) [Rossi, 2001]
- This is when hamstrings are maximally stretched.
Pelvic Avulsion Fracture: Presentation
- Popping or snapping sensation coinciding with physical exertion
- A prodrome of low-grade pain affecting the site may have been present for several months prior to the injury; consistent with apophysitis. [White, 2002]
- Point tenderness over the region.
- Swelling may be present.
- Range of motion (both active and passive) may be completely normal.
- Meralgia paresthetica can be associated. [Hsu, 2014; Hayaski, 2011]
- Entrapment of the lateral femoral cutaneous nerve
- Leads to pain, burning, and numbness over the anterior and lateral thigh.
- Can occur because of compressive hematoma [Hsu, 2014] or entrapment by avulsed fragment. [Hayaski, 2011]
- First choice for imaging. [Rossi, 2001]
- Nearly all (99%) in one series were identified via plain radiographs. [Schuett, 2015]
- Often able to demonstrate avulsion of the involved apophysis.
- May need oblique, frog-leg, and/or axial projections
- If the apophysis has not yet ossified, may be occult on radiographs.
- Can be used to demonstrate local hematoma formation. [Hsu, 2014]
- CT and MRI are usually reserved for obscure cases or in the setting for surgical planning.
Pelvic Avulsion Fracture: Treatment
- Therapy consists primarily of conservative management:
- Brief period of rest followed by,
- Protected weight bearing followed by,
- Progressive stretching followed by,
- Strengthening routine followed by,
- Gradual return to sports
- Surgical treatment (open reduction and fixation)
- Conservative and surgical therapies lead to similar outcomes. [Kautzner, 2014]
- Surgery is indicated in 3% of cases. [Schuett, 2015]
- Surgery can lead to Full ROM sooner and tolerance of weight bearing and exercise can be achieved earlier. [Kautzner, 2014]
- Surgery may be preferred for competitive athletes and those with greater displacement (>2 cm) of fracture fragments. [Kautzner, 2014]
Moral of the Morsel
- Before you diagnosis a “hip sprain,” consider the age, mechanism, and those tricky growth plates! Kids are less likely to “sprain” and more likely to avulse a growth plate.
- The adolescent athlete has the perfect storm of physical activity, strong muscles, and weak growth plates. Keep pelvic avulsion fracture on your differential for the adolescent with thigh, hip, and pelvic pain that occurs after sporting activity.
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