One of the great aspects of working in my ED is being surrounded by a multitude of amazing and brilliant teammates. One, Dr. Christyn Magill, recently provoked this Morsel of knowledge: just because it ends in “-itis” does not mean it needs antibiotics! Excellent point! We have covered this previously with Sinusitis, but another excellent example of this notion is Epididymitis!! Let us take a moment to review how Epididymitis in Children:
Acute Scrotal Pain
- Acute scrotal pain is not uncommon in the Peds ED.
- We have previously discussed some conditions that are related to scrotal pain:
- The most common concerns, however, are:
Acute Epididymitis in Children
- Epididymitis is not rare in children.
- Older literature described it as a rare condition, but newer research shows greater frequency of disease than previously known. [Nistal, 2016; Redshaw, 2014]
- Majority of cases occur in prepubertal / early adolescent boys (11-14 years). [Redshaw, 2014; Santillanes, 2011]
- Comprises up to 35-65% of all acute scrotal pain cases. [Nistal, 2016]
- Epididymitis is often considered to be due to an infection.
- Older males often have reflux of urine due to prostatic hypertrophy.
- Young males (<35 years) often have an associated sexually transmitted disease.
- What about the children who are not sexually active?
- In young children, the INCIDENCE of infection is LOW. [Nistal, 2016; Santillanes, 2011]
- Of ~1,500 patients with acute epididymitis, only ~15% had positive urine cultures. [Cristoforo, 2016]
- Unfortunately, >85% still received antibiotics. [Cristoforo, 2016; Santillanes, 2011]
- In the end, the majority are classified as idiopathic. [Redshaw, 2014; Min Joo, 2013]
- True etiology is still not fully understood.
- May be due to:
- Inflammation from adjacent torsion of appendix of testis
- Reflux of sterile urine
- Viral illness (ex, Mumps, Coxsackie B, influenza, EBV)
- Anatomic abnormalities (likely in younger patients)
- Epididymitis is usually a unilateral process. [Nistal, 2016]
- The right side is affected more often.
- Hydrocele is usually observed along with local symptoms of inflammation.
- 1st, don’t overlook the potential for torsion as the etiology!
- Distinguishing epididymitis from testicular torsion clinically can be difficult. [Redshaw, 2014]
- Have low threshold for obtaining Ultrasound.
- If history, exam, and U/S are consistent with epididymitis, consider the age:
- Young boys who are not sexually active
- Low risk for infectious etiology. [Cristoforo, 2016; Santillanes, 2011]
- May wish to treat based on abnormal urinalysis.
- Could also wait until Urine Culture results, as rates of true infections are slow low. [Cristoforo, 2016; Santillanes, 2011]
- Treat with NSAIDs, scrotal support, and rest
- Sexually active boys
- At risk for STDs!
- Consider testing and starting empiric therapy.
- Also can use NSAIDs, scrotal support, and rest (and AVOIDING SEX!).
Moral of the Morsel
- Don’t overlook torsion! Think of epididymitis as the potential cause of acute scrotal pain in young boys, but check that ultrasound!
- Just because it has “-itis” at the end of the word, does not mean it is an antibiotic deficiency!
- There is an abundance of antibiotics given to boys with epididymitis who have a low risk for infection. Don’t add to the problem. (see C. Difficile)
- Check a Urine Culture (maybe even resist the urge to react to a urinalysis) and educate the family.
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Have you ever been told that something “isn’t a big deal” only to later find out that it was? Of course, any one who is in a significant relationship with another person has experienced this phenomenon. I, myself, may be at fault (once in a blue moon). Often, when I evaluate intra-oral injuries I will tell families that the mouth heals very well and seldom requires primary repair (ex, Tongue Lacerations). Naturally, there are other intra-oral injuries that do warrant more contemplation and concern (ex, Tonsillar Injuries). A lip frenulum tear, however, is “no big deal.” Right? Well… let us just remain vigilant.
- The upper lip has the Superior Labial Frenulum and lower lip has the Inferior Labial Frenulum.
- Also referred to as a Frenum.
- These are folds of mucous membrane that are midline and extend from the gingiva to the lips.
- They can be easily torn when the mouth is hit or the lip is pulled/stretched.
- Often bleeds “a lot” (as many injuries to the face/mouth do), but usually will spontaneously stop bleeding.
Frenulum Tear: Management
- This is easy… management is reassurance that it will heal fine on its own!
- Let families know that they may bleed intermittently if people keep pulling open the lip to see the injury.
- Simple pressure on outside of lip usually is enough to stop bleeding.
- May want to advocate for a soft mechanical diet for a few days to help avoid reopening the wound with sharp crackers and chips (the typical diet of most American kids).
- Does not typically require specific closure or intervention.
- Heals well on its own without primary closure.
- If the tear is more than the frenulum, extending to the surrounding gingiva, repair may be necessary – be sure to use absorbable sutures!
Frenulum Tear: It is Trauma!
- Ok, so the previous statement was a bit cavalier… there is obvious trauma to the mouth… so, let us remain vigilant and be sure to consider other injuries.
- Evaluate head to toe and look for other injuries, like:
- Unfortunately, another consideration needs to cross your mind: Non-Accidental Trauma / Abuse.
- A frenulum tear is NOT pathognomonic for abuse, but intra-oral injuries are seen in a significant number of abuse cases. [Maguire, 2007]
- The history, obviously, plays an important role in helping to raise concern for abuse.
- Knowing the developmental milestones can help determine whether an reported cause of injury would be reasonable.
- A 2 month old would not have caused her/his own frenulum tear by falling.
- An 18 month old may have fallen an hit the lips on a table edge.
- Non-ambulatory children with facial injuries should raise your level of concern for abuse. [Starr, 2015; Thackeray, 2007]
- The most frequently reported abusive injury to the mouth is injury to the lips, but a frenulum tear in isolation does not equate to abuse. [Maguire, 2007; Thackeray, 2007]
- Several abusive mechanisms have been proposed to cause a frenulum tear: [Maguire, 2007]
- Forceful feeding
- Forceful placement of a pacifier
- Gripping or stretching of the lip
- Vigorous rubbing of the lip
- Direct forceful blow to lip
Moral of the Morsel
- A frenulum tear can be managed with simple, non-surgical interventions.
- A frenulum tear is intra-oral trauma. Remain vigilant and evaluate for other trauma.
- Undress the child and look for other trauma. I know it is tempting to just look in the mouth… but be thorough and look for other signs of non-accidental trauma.
- A frenulum tear is not pathognomonic for abuse, but make sure the story and developmental milestones make sense.
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Performing procedures is obviously an important aspect of what we do in the Emergency Department. Our procedural prowess is depended upon by our patients and their families. We have discussed several procedural strategies previously (ex, Suturing, Tongue lacerations, Spinal Tap, ETT placement, Pigtail Thorocostomies, Transillumination of Ptx, and many more). One common condition that often requires a procedure is the subcutaneous abscess. We have previously discussed whether antibiotics are needed for abscesses. Now let us look at whether there is another strategy to the classic incision and drainage: Incision and Loop Drainage.
Loop Drainage: The Technique
This technique is described by several paper – [Aprahamian, 2016; Ladde, 2014; Ladd, 2010; Tsoraides, 2010]
Aprahamian, 2016 recommends it as the “definitive treatment of choice for subcutaneous abscesses in children.”
- Incise lateral edge of abscess cavity.
- Break up the loculations.
- Insert small curve hemostat or small needle driver through small incision.
- Gently explore abscess cavity and break up loculations.
- Find edge of abscess cavity.
- While probing the cavity, determine the dimensions of the cavit.
- 2nd incision in this region.
- Ideally, make second small (4-5mm) incision within 4 cm of the first.
- For very large abscess cavities, you can use additional small incisions.
- 3 or 4 incisions with each being ~ 4cm apart from the other.
- Irrigate and get the pus out!
- Now with an ingress and an egress, you can decompress the abscess.
- Irrigation can help remove debris.
- Pass vessel loop, sterile rubber band, or Penrose Drain though two incisions.
- Vessel loop work very well for this as it is a small calibre and is easy to tie.
- Tie ends together, ensuring no tension on skin.
- Use a surgeon’s knot for the first tie.
- Ensure that there is plenty of slack to avoid tension on the skin.
- Tie multiple other knots tightly on top of the surgeon’s knot to ensure security.
- (yes… I know this abscess looks like it has a lot of Vitamin C…)
Loop Drainage: Home Care
- Keep area clean.
- Can cover with gauze to absorb the residual drainage.
- Can shower and/or bathe.
Loop Drainage: The Removal
- The loop drain can removed once:
- Drainage has stopped.
- Cellulitis has improved.
- Usually is within 7-10 days.
Loop Drainage: The Benefits
- Minimizes scarring (two small incisions instead of one large one). [Aprahamian, 2016]
- Eliminates the need for repeat visits for wound packing changes. [Aprahamian, 2016]
- This saves the patient / family the time of returning multiple times.
- Also saves the patient the pain and anxiety of having the packing changed.
- Also saves ED visit cost.
- In theory, the loop could be removed by any provider (PCP, Urgent Care, etc).
Aprahamian CJ1, Nashad HH2, DiSomma NM3, Elger BM4, Esparaz JR5, McMorrow TJ4, Shadid AM4, Kao AM3, Holterman MJ1, Kanard RC4, Pearl RH6. Treatment of subcutaneous abscesses in children with incision and loop drainage: A simplified method of care.
J Pediatr Surg. 2016 Dec 30. PMID: 28069270
. [PubMed] [Read by QxMD]
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Wound care is a common issue in the ED. Certainly, not all wounds are created equal. We have discussed eyelid lacerations and tongue lacerations. We have also discussed my favorite wound closure technique: tissue adhesives. While tissue adhesives are pretty awesome, they aren’t appropriate for all scenarios. Sometimes you need sutures. I was taught that you use absorbable sutures to close deep layers and non-absorbable to close the surface. Pretty simple and made sense; however, removal of sutures is not always simple and sedating a child just to remove strings doesn’t seem to make much sense. Recently, there has been an evolving trend that challenges the myth that all skin closure is done with non-absorbable suture. Let us take a minute to digest a Morsel of information about Absorbable Sutures for primary wound closure.
- The primary purpose of sutures is to hold apposing tissues together to facilitate healing, while minimizing scar and complications.
- There is no single suture material that is suitable for all wounds. [Dennis, 2016]
- Choice of suture depends upon a number of factors:
- Wound tension (strength of suture)
- Depth and number of tissue layers involved
- Presence of edema
- Expected time of wound healing
- Inflammatory reactions from suture
- Ease of use
- Security of knot
Absorbable Sutures: Examples
- Absorbable suture = suture that undergoes degradation and absorption in tissue.
- Polyglactic 910 (ex, Vicryl) [Hochberg, 2009]
- Retains 65% of its tensile strength at 2 weeks; 40% at 3 weeks.
- Complete absorption occurs between 60 and 90 days.
- Very useful for completely buried sutures apposing deep tissues.
- Rapid Absorbing Coated Polyglactic 910 (ex, Vicryl Rapide) [Hochberg, 2009]
- Partially hydrolyzed and processed to speed up absorption.
- 50% tensile strength at 5 days; 0% at 2 weeks.
- Sutures can be absorbed in 10-14 days.
- Poliglecaprone (ex, Monocryl) [Hochberg, 2009]
- Retains ~40% of its tensile strength at 2 weeks.
- Absorption is in ~90-120 days.
- Has significant initial tensile strength, so closure can be done with a suture 1-2 sizes smaller than normal.
- Good for subcuticular closure.
- Gut [Hochberg, 2009]
- Made from twisted strands of purified collagen prepared from sheep or cattle small intestine.
- Comes in three varieties: Chromic, Plain, and Fast-Absorbing
- Chromic gut is tanned to decrease absorption rate. Absorption in 21 days.
- Plain gut is untreated. Absorption in 10-14 days.
- Fast-absorbing gut is head-treated to increase absorption rate. Absorption in 7 days.
- Fast-absorbing gut has less tensile strength than plain gut.
- Fast-absorbing gut is used primarily for epidermal suturing.
Absorbable Sutures: For Lacerations
- Controversy exists over using absorbable sutures for epidermal wound closure.
- Some avoid absorbable sutures due to “concerns” for increased scar formation, increased wound dehiscence, and increased wound infection.
- Others advocate for absorbable suture use, particularly in children, as it may avoid the challenges of having to remove sutures.
- There are several studies that demonstrate the utility and safety of using absorbable sutures, specifically in children. [Tejani, 2014; Luck, 2013; Luck, 2008; Karounis, 2004]
- Vicryl Rapide has been shown to be useful in closure of simple lacerations on the trunk and extremities. [Tejani, 2014]
- Fast-absorbing gut showed no significant clinical difference to non-absorbable suture for facial lacerations at 3 months. [Luck, 2008]
- Fast-absorbing gut did not have higher rates of wound infection or complications compared to non-absorbable. [Luck, 2008]
- Plain gut has also been found to be an acceptable alternative to non-absorbable suture for pediatric wound repair. [Karounis, 2004]
- So it would appear that the concerns about increased scar formation, wound dehiscence, and infection should not be as concerning as we may have been taught.
Absorbable Sutures: Proposed Strategy
- Always take care to anticipate the patient’s pain/anxiety to help avoid causing post-wound repair PTSD!
- Consider nitrous oxide or intranasal medications even if you don’t think you will need full procedural sedation.
- This may help when the patient returns for wound reassessment, etc.
- Default to using absorbable sutures in children when sutures are required.
- Consider using Vicryl Rapide for extremities and trunk.
- Consider using Fast-Absorbing Gut for facial lacerations.
- If there is too much tension at the epidermal wound edges, consider deep layer closure.
- This may then allow for absorbable suture closure at the surface.
- Obviously, some wounds will still require non-absorbable sutures (ex, over joints, high tension).
- Still recommend removal of absorbable sutures at the appropriate time interval.
- This is particularly useful in areas that heal more rapidly than the suture dissolves (i.e., the face).
- Removing the suture may help to continue to minimize scar formation risk.
- If the child will not easily and calmly tolerate suture removal, the presence of the absorbable sutures allows for the suture removal procedure to be aborted.
- Simply trim down the sutures as much as allowed.
- Can recommend some gentle massage to help speed up the absorption process.
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Caring for people, particularly children, can be very humbling. Just when you think you have a grasp of the potential hazards and pitfalls, a new zebra runs you over. While focusing extensively on “zebras” can be counterproductive, it is useful to know that they do exist. We have previously covered a few “zebras” (ex, Pheochromocytoma, Gradenigo’s Syndrome, Osteosarcoma, Hypertensive Emergency, Cerebral Venous Thrombosis) and hopefully this will help us spot those stripped creatures running with the horses. Another zebra came close to running me over the other day. Let us take a minute to review Colonic Pseudo-Obstruction, Ogilvie’s Syndrome.
Ogilvie’s Syndrome: Basics
- Also known as Acute Colonic Pseudo-Obstruction
- First described by Sir Heneage Ogilvie in 1948.
- Colonic obstruction WITHOUT evidence of an organic / mechanical obstruction.
- It has limited small bowel involvement (which distinguishes it from adynamic ileus).
- Nausea and vomiting
- Abdominal pain
- Obstipation (which sounds terrible)
- Abdominal distension
Pathophysiology is still not clear: [Hooten, 2014; Shukla, 2007]
- May be due to suppression of sacral parasympathetic nerves.
- May be due to increased sympathetic tone inhibiting colonic motility.
- May be due to prostaglandin abnormalities.
Who’s at risk:
- Acutely critically ill patients (ex, Sepsis, Trauma, Metabolic derangements, Peritonitis, Kawasaki Disease) [Shukla, 2007]
- Chronically ill patients (ex, Malignancies, Spinal injury, Diabetes, Sickle Cell Disease) [Khosla, 2008]
- Post-operative patients [Hooten, 2014; Jiang, 2007]
- Medications that affect the bowel (ex, narcotics, sedative/hypnotics, TCAs)
- It is a clinical diagnosis.
- Requires exclusion of other mechanical obstructions.
- No specific laboratory studies.
- Abdominal Plain Films are most useful and show: [Shukla, 2007]
- Colonic and cecal dilation
- Normal austral markings
- Thin colonic wall
- Gasesous distension with little fluid in bowel lumen (so unlike mechanical obstruction with air-fluid levels)
- No established criteria for colonic diameter for pediatric patients. [Shukla, 2007]
Ogilvie’s Syndrome: The Problem
- Despite there being no mechanical obstruction, the condition can lead to significant morbidity and mortality.
- Dilation of the proximal colon leads to retention of large quantities of fecal material and gas.
- This further increases dilation of the colon.
- Intraluminal pressures in the proximal colon increase.
- The increased pressure negatively impacts the capillary blood flow to the intestinal tissue.
- Ischemia, gangrene, and perforation can occur.
Ogilvie’s Syndrome: Treatment
- Ensure that there is not a surgical process first (i.e., rule out mechanical obstruction).
- Treat the underlying medical conditions. (ex, hyponatremia)
- Conservative therapies are preferred: [Shukla, 2007]
- Bowel rest
- Nasogastric decompression
- Rectal tube decompression (if distention extends to sigmoid region)
- Discontinue offending medications
- Neostigmine [Hooten, 2014; Khosla, 2008; Gmora, 2002]
- Erythromycin [Jiang, 2007]
- Colonoscopic decompression is reserved for those who fail conservative therapies and medicines.
- Cecostomy may be required for patients with ischemia, perforation, peritonitis or failure of other therapies.
Moral of the Morsel
- Add this condition to your list of concerns for abdominal distention, particularly in the critically ill or chronically ill.
- While we might not start neostigmine in the ED for this, it is good to know conservative management and bowel decompression are important to start as soon as the bowel distention is noted.
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