Certainly, knowing critical care topics (ex, ECMO in ED, Submersion Injuries, Optimize Chest Compressions, and Non-Invasive Ventilation) is vital to being effective in the ED, but mastery of less critical topics (ex, Rash Evaluation, Recurrent Abdominal Pain, Growth, Development, and Fish Hook Injuries) helps optimize efficiency in the ED. One issue that can derail a “simple” evaluation is Cerumen Impaction.
Cerumen: It’s Natural!
- Cerumen might repulse parents and hinder your ability to see the Tympanic Membrane (TM), but it serves a purpose.
- Emollient of the ear canal
- Bactericidal material
- Cerumen is a mixture of:
- Epithelial cells from the TM and canal,
- Secretions from apocrine sweat glands,
- Dirt and small particles.
- The Cerumen naturally migrates from the middle aspect of the canal outward.
- Like a good stove, the ear is “self-cleaning.”
- Movement of the jaw assists with the nature migration outward.
- So, anything that interferes with this process can lead to impaction.
- Anatomic anomalies (ex, stenotic ear canals seen with Down’s Syndrome)
- Excess cerumen production
- Ear Plugs
- Cotton-Tip Applicators
- Commonly associated with cerumen impaction [Macknin, 1994]
- Do more harm by pushing cerumen deeper and leaving cotton fibers behind.
- Good to reinforce avoiding the use of these, or any objects, to insert into the ear canal.
- Foreign Bodies
- Hearing Aids
- Cerumen impaction is present in ~10 % of children.
- Impaction does not require complete obstruction of the canal.
- Impaction implies symptomatic state or obscuring the view of the TM.
- Cerumen impaction symptoms:
- Hearing loss
- No single way is perfect, so knowing several is useful. [Roland, 2008]
- Manual Removal
- Curettage with direct visualization using cerumen “spoons”
- Risk of trauma to ear canal and/or TM
- Benefit is that it does not introduce moisture into the canal.
- Cerumenolytic agents
- Chemicals that soften / emulsify cerumen
- Several options, but none have been proven to be superior to any other, and saline is just as effective. [Burton, 2009]
- Seem to work best when applied 15-30 min before irrigation.
- Some common options:
- Liquid Docusate Sodium – 150mg/15mL, 1 mL in ear canal.
- Triethanolamine polypeptide oleate-condensate (AKA, Cerumenex) – fill canal with liquid and irrigate in 15-30 min.
- Multiple over the counter products available.
- Risk of skin irritation, pain, and vertigo (if TM is not intact).
- Effective, but most efficient (using less fluid) if preceded by cerumenolytic.
- Risk of trauma and pain.
- Systems or techniques that direct fluid toward wall of ear canal, rather than directly toward the TM are preferred. [Roland, 2008]
Moral of the Morsel
- Ok, so having a Morsel about cerumen impaction seems less than exotic and cutting edge, but sometimes we can get carried away with digging in kids’ ears.
- Before you go wrestling the kid to the ground with a hard, icepick-like device poised precariously above the TM or before you order that docusate and add 30 min to the ED stay, ask yourself, is this a Cerumen Impaction?
- Is this cerumen potentially causing the child’s symptoms (ex, pain, dizziness, cough)?
- Is this cerumen obscuring my view of the TM and is visualizing the TM important to me today?
- This is where the idea of watchful waiting for Acute Otitis Media comes into play.
- If the child presents with a fever and is over 2 years of age, even if there is a definitive AOM, watchful waiting would be appropriate.
- Digging in, or irrigating, the child’s ear canal will likely cause redness of the TM and canal, potentially complicating the diagnosis even after cerumen removal.
- If watchful waiting is appropriate, perhaps it is just as good to discuss with the family that the presentation is consistent with a febrile illness, which may also include an AOM, but rather than wrestle the child today, we could apply cerumenolytic at home over the next 1-2 days, and then have the child and ear re-examined if ear symptoms persist.
- Share Decision Making may take you a little bit of time to explain and discuss, but may save you time and sweat in the end.
Roland PS1, Smith TL, Schwartz SR, Rosenfeld RM, Ballachanda B, Earll JM, Fayad J, Harlor AD Jr, Hirsch BE, Jones SS, Krouse HJ, Magit A, Nelson C, Stutz DR, Wetmore S. Clinical practice guideline: cerumen impaction.
Otolaryngol Head Neck Surg. 2008 Sep;139(3 Suppl 2):S1-S21. PMID: 18707628
. [PubMed] [Read by QxMD]
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Remaining vigilant for the child with a subtle presentation of a severe illness is part of our job in the Ped ED; however, sometimes, the illness is not subtle and the child requires critical actions (ex, Damage Control Resuscitation, Mechanical Ventilation, Optimize Chest Compressions) . Often, it is best to consider these critical actions prior to needing to do them so there is no delay. One such, potentially life-saving, critical action is Extracorporeal Membrane Oxygenation (ECMO). Recently there was a nice review of Pediatric ECMO [Gehrmann, 2015] that deserves further contemplation. Below are some highlights from that article:
- ECMO utilizes an external circuit to oxygenate blood and remove carbon dioxide.
- It has been successfully used in the NICU for respiratory failure since 1970’s.
- ECMO is not a therapy to correct a medical condition; it is used to support a patient while definitive strategies are able to correct the problem, or “time heals the wounds.”
- ECMO essentially buys a patient some time.
- Used for patients who have reversible cardiac or respiratory failure.
- In the NICU that includes:
- Meconium aspiration
- Persistent fetal circulation
- Congenital diaphragmatic hernia
- Pulmonary hypertension of the newborn
- Basic circuit has:
- Vascular cannulas for access – one to extract blood and one to replace it.
- Pump and Tubing
- Gas-exchanger – to add the oxygen and extract the carbon dioxide.
- Heat exchanger – to ensure that the blood returns to the patient at safe temperature.
ECMO: VA vs VV
- The circuit can be completed through two modes: Venoarterial (VA) or Venovenous (VV).
- Accesses major vein (ex, IJ, Femoral Vein) and major artery (ex, Carotid)
- Able to provide circulatory support as well as oxygenation.
- Can be used for patients with primary heart failure.
- Access two major veins (ex, IJ, Femoral Vein) or uses a double-lumen catheter to access one major vein (ex, IJ).
- Advantage over VA is the lack of needing to access and repair major artery.
- Less risk for ischemic injury or thromboembolic complications.
- Provides oxygenation, but because oxygenated blood returns to venous side, the oxygenation level will be lower compared to VA.
- Does not provide circulatory support and cannot be used for heart failure.
- Well suited for reversible acute respiratory failure.
ECMO: in the Ped ED
- ECMO is the last option when standard management has failed and:
- the condition causing cardiopulmonary failure is reversible or
- the organ transplantation is an option.
- While it is the last option, considering it at the last minute will not help, as it requires time to coordinate with the teams and time to gain access and set up the system.
- Common conditions ECMO is used for:
- Newborns and infants:
- Children and Adolescents
- Status asthmaticus
- Submersion injury
- Acute chest syndrome
- Traumatic pulmonary contusion
- Intractable dysrhythmias
- Beta blocker / calcium channel blocker poisoning
- Hypothermia – as a means to rewarm
- Cardiac arrest
- E-CPR (Extracorporeal Cardiopulmonary Resuscitation)
- ECMO as a rescue therapy for cardiac arrest.
- American Heart Association lists it as an option for In-Hospital Cardiac Arrest if condition is thought to be reversible or amenable to heart transplantation.
- Effectiveness is higher when started within 30 min after cardiac arrest. [Tajik, 2008]
- Proper patient selection is important, although there are no clear guidelines.
Moral of the Morsel
- ECMO is not commonly needed in the ED, but on the rare occasion that it will be helpful, the means to initiate it need to already been known, as time is critical.
- Having a protocol in place (hopefully, never to be needed) to help with patient selection and streamline the activation of the “ECMO Team” may literally save a child’s life.
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Obviously, as the leading cause of mortality in children, traumatic injuries warrant significant attention. As such, the PedEM Morsels have covered various traumatic topics (ex, Abdominal Trauma, Aortic Injury, Traumatic Ptx, Pulmonary Contusion, and C-Spine Clearance), but one issue deserves specific attention: the Pelvic Fracture.
Pediatric Pelvic Fracture: Basics
- Pediatric pelvic fractures are relatively rare.
- Reported incidences range from 2% to 7.5% of all blunt trauma.
- Pediatric trauma patients are less likely to suffer a pelvic fracture.
- Adults are twice as likely to have a pelvic fracture. [Demetriades, 2003]
- This is is true across all common mechanisms (ex, Fall from height, MVC, pedestrian strike).
- Mortality is, fortunately, low in children. [Demetriades, 2003]
- Pediatric pelvic fractures, like in adults, indicate high-energy mechanism.
- Pelvic fractures are associated with other life-threatening injuries.
- 11-20% have concomitant solid organ injuries.
- ~5% have small bowel injuries. [Demetriades, 2003]
- Aortic injuries were only found in adult patients. [Demetriades, 2003]
- The severity of pelvic fracture is correlated with mortality. [Swaid, 2015]
Pediatric Pelvic Fracture: Different than Adults
- Mechanism is often different between adults and children.
- Children are more likely to be pedestrians who are struck or by passengers in the rear seat of car and sustain lateral impact.
- Adults more likely to be in driver’s seat and have direct AP compression, leading to greater chance of “open-book” pelvis.
- The pediatric pelvis is structurally different from the adult pelvis.
- The immature pediatric pelvis is plastic and requires greater force to fracture.
- Much of the pelvis is composed of cartilage in the young.
- Sacroiliac joints and pubic symphysis are more elastic.
- The pediatric bone has thicker periosteum than adult bones.
- The elasticity of the pediatric pelvis allows it to absorb energy and dissipate it before it breaks.
- The pediatric pelvis is able to a suffer single, displaced ring fracture while adults more often have two fracture sites within the ring.
- The immature pediatric pelvis bleeds less.
- The thicker periosteum is helpful in containing hemorrhage.
- Vasculature is more able to constrict, further reducing bleeding.
- The pelvic volume is also lesser in children, which can help tamponade bleeding.
- WARNING: this may actually lead to misperception of stability. [Amorosa, 2014]
- The pediatric patient is able to heal better than adults.
- Great capacity to remodel bone.
- Osteoblast to osteoclast ratio in children favor bone growth and remodeling.
Pediatric Pelvic Fracture: Classification
- There are several classifications, but the most commonly used one is developed by Torode and Zeig. [Torode, 1985]
- Based on CT imaging a Modified Torode and Zeig classification has recently been created. [Shore, 2012]
- Torode I – Avulsion Fractures
- Avulsion of bony element, often associated with adjacent growth plate.
- Associated with sporting injuries (ex, gymnastics). [Ortega, 2014]
- Not due to high-energy mechanisms.
- Torode II – Iliac Wing Fracture
- Disruption of the iliac apophysis.
- Due to direct lateral force.
- Torode III A – Simple Anterior Ring Fracture
- Pubic rami or pubic symphysis fractures.
- Stable on clinical exam.
- Have similar resuscitation requirements to lower classifications. [Shore, 2012]
- Torode III B – Stable Anterior and Posterior Ring Fractures
- Both anterior and posterior ring segments involved.
- Stable on clinical exam.
- Have similar resuscitation requirements (increased blood transfusion requirements, ICU days, and length of stay) to Torode IV.
- Torode IV – Unstable Ring Disruption
- Ring disruptions, hip dislocations and combined pelvic and acetabular fractures.
- Stability is determined clinically and radiographically. [Shore, 2012]
- Clinical stability to AP compression and
- < 2 mm of fracture displacement on CT
Pediatric Pelvic Fracture: Management
- For us in the ED, manage as you would any trauma patient:
- Airway, Breathing, Circulation
- Thorough secondary survey
- Children will less likely require pelvic binding, but if there is ring disruption or clinical instability, do not hesitate to place pelvic binder.
- There is variability amongst orthopods in the management of pediatric pelvic fracture. [Vitale, 2005]
- In general, the pediatric pelvic fracture is managed non-operatively.
- Operative repair has been favored for those with unstable pelvic fractures. [Amorosa, 2014]
- The status of the triradiate cartilage ossification is critical in the determination of management.
- The triraditate cartilage closes on average around 12 years in girls and 14 years in boys.
- If the triradiate cartilage has not fused, the pelvis is considered immature.
- After closure of the triradiate cartilage, the pelvis is structurally more like an adult pelvis and can be classified and treated similar to adults. [Amorosa, 2014]
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Kids love to explore their worlds. That exploration, especially when combined with immature decision making and slow reflexes, can lead to foreign bodies of all sorts becoming lodged in body parts of all kinds. Appropriately, previous Ped EM Morsels have discussed several foreign body topics (ex, Aspirated FB, Ear FB, Delayed Dx of Aspirated FB, Button Battery FB, Nasal FB). There is another type of foreign body that can be particularly challenging to deal with: The Fishhook.
Anglers are Awesome, but Fishhooks are Frustrating
- We are all aware of the benefit of “teaching a man to fish,” (you feed him for a lifetime) but teaching someone how to remove a fishhook is just as valuable!
- Fishhooks are perfectly designed to penetrate flesh and remain in place.
- The distal point penetrates efficiently.
- The barb locks it in place.
- Fishhooks often become embedded within areas that have delicate and sensitive structures:
- Face / Scalp
- Eyelid [Subramaniam, 2015, Deramo, 1999]
- Tongue [Eley, 2010]
- Removal of an embedded fishhook is more challenging when it is in these sensitive regions.
- The fishhook puts local structures at risk of injury.
- The process of removing it also puts the regional tissue at risk.
Fishhook Foreign Body: Initial Evaluation
- Not all hooks are the same… how many barbs does this one have?
- The patient, if an angler, may know.
- An X-ray may be helpful to determine this. Can also evaluate local structures.
- Local structures
- Refrain from yanking on the fishhook until you have contemplated potential involvement of local structures.
- Are tendons, nerves, or blood vessels involved?
- Bedside Ultrasound may be of benefit to help define depth and local structure involvement.
- Pain management – Don’t Be Cruel!
- Appreciate the child’s apprehension and pain before you do any manipulation.
- By making them comfortable first, you may even be able to avoid procedural sedation (an ounce of prevention, beats a pound of therapy).
Fishhook Foreign Body: Removal Techniques
- As with any procedure, knowing several methods can help you deal with the wide variety of variables that may occur.
- Before proceeding with any tactic, consider patient comfort, position, and safety.
- Since it is the barb that is causing the issue, it helps to think of how to neutralize its effect.
- The below are nicely outlined in multiple references, including [Subramaniam, 2015, Prats, 2013].
- DISENGAGE THE BARB
- Downward pressure on the shank can help disengage the barb from the tissue track.
- For superficial fishhook and the barb is small:
- May be able to remove it by reversing through its path.
- Least likely to work, but worth a single attempt sometimes.
- For more deeply embedded or larger barbed fishhooks:
- Wrap a large caliber suture around the distal curve.
- Stabilize surrounding skin.
- While depressing shank, yank the string parallel to the line of the shank.
- Useful when sensitive structures are not involved.
- COVER THE BARB
- An ~18-gauge can be used to cover and disengaged the barb.
- Technically, this is challenging, as it requires accurate location of the barb in 3 dimensions. Easier to do with superficial fishhooks.
- Advance the needle parallel to the shank, along the entry wound.
- The bevel of the needle should face the barb and advanced until the barb is sheathed within the needle.
- Once the needle covers the barb, both needle and fishhook are reversed through the wound opening together.
- CUT THE BARB
- If the fishhook has passed completely through tissue and:
- The barbed end is more accessible,
- Cut the barbed end.
- Reverse the remaining shank back out of the entry wound.
- The shank is more accessible,
- Cut the shank end.
- Grab the barbed end and remove through the exit wound.
- If the fishhook has not passed completely through the tissue:
- Use needle drivers to advance the fishhook through the skin.
- Choose to cut either the barbed end or the shank as above.
- EXCISE THE BARB
- For a deeply embedded fishhook or one adjacent to very sensitive structures, creating a new path to remove it may be best option.
- May require specialist involvement (ex, orthopaedist, ophthalmologist). [Deramo, 1999]
Fishhook Foreign Body Wound Care
- Consider other retained foreign bodies.
- Local Wound Care with topical antibiotics
- Empiric systemic antibiotics are not routinely required in the otherwise healthy patient.
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Obviously, the audience (you all) who read these Morsels love critical care topics (Post-Tonsillectomy Hemorrhage has been the most viewed Morsel since it was written in 2012), but excellent care in the Peds ED often requires some considerations that emergency providers don’t often list in their skill set. Issues that we might assume are in the realm of the Primary Care provider (ex, Asthma Control, Developmental Milestones, Firearm Safety, Submersion Prevention, and Injury Prevention) actually can play critically important roles in the management of our patients in the ED. One such topic is Vaccinations. We need to help children stay healthy by giving at risk patients the Influenza Vaccination.
Vaccination in the ED is NOT Unusual
- The ED is a critical frontier for public health.
- This is certainly true for critical injuries and illnesses.
- It is also true for sub-acute and chronic disorders.
- It has an equally important role in injury and illness prevention.
- The ED has already been administering vaccinations as part of appropriate care.
- Every time someone scratches their skin, we “update the tetanus.”
- Now, this actually should include “update the diphtheria.” [CDC Tdap Recommendations]
- Influenza is highly contagious.
- Influenza can may cause mild disease, but can also lead to severe illness and complications. [CDC, Disease Burden]
- Anyone can contract the illness, but there are special populations who are at greater risk from the disease:
- >65 years of age
- Pregnant (and up to 2 weeks post partum)
- Residents of long-term care facilities
- Children <5 years of age (particularly <2 years of age)
- Patient with chronic medical problems (abridged):
- Influenza Vaccination has proven to be an effective means to reduce influenza-related morbidity.
- Vaccination of one group of at risk patients can also reduce influenza-related morbidity morbidity in other groups. [Gatewood, 2011]
- Unfortunately, influenza vaccination is still underused among at risk patients. [CDC, Flu Vaccination Rates]
Vaccination for Influenza in the ED
- The vast majority of the vaccination should occur in the outpatient environment, but there are potential barriers to achieving this:
- Lack of access to primary care office visit during the vaccination period
- Lack of education about specific risk
- Lack of education about recommendations
- Parental preference / concern for vaccine safety [Strelitz, 2015]
- Provider discomfort (hopefully, you are less uncomfortable now)
- An ED visit offers an opportunity to influence many of these barriers.
- Certainly discussing influenza, at risk populations, and the recommendations can improve awareness and influence subsequent vaccinations. [Dappano, 2004]
- Offering the influenza vaccination in the ED has also proven to be helpful. [Dappano, 2004]
- Having a concurrent illness should not prevent vaccination.
- The largest group of at risk patients we encounter in the ED are patients with asthma.
- Does being on steroids interfere with the vaccination? NO.
- Influenza vaccination can be given safely and effectively to kids with an asthma exacerbation even if they are on steroid therapy. [Park, 1996]
Moral of the Morsel
- Providers in the ED encounter patients when they are most receptive to education about their illness.
- Patients with asthma are often cared for in the ED and are one of the at risk populations.
- Help prevent that patient from returning to the ED or causing someone else from becoming ill by expanding the exposure to influenza vaccination.
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“Rash” seems to be a ubiquitous complaint some days in the Ped ED. Knowing that the skin is the largest organ, it seems only appropriate that we should take these complaints seriously. Unfortunately, often I feel a little inadequate when trying to decipher the code of the Pediatric Rash. Below is a simple approach I use to help ensure I don’t over-diagnose viral exanthem.
Pediatric Rash Step 1: Sick or Not Sick
- This speaks for itself.
- Treat aggressively!
- The skin findings may help clue you in to the source of the sickness, but don’t let pontification of the unusual rash delay your rapid administration of necessary care!
- Not Sick?
- Don’t be cavalier, just yet!
- Not appearing sick is reassuring, but kids can be deceptive!
- Remain vigilant and move to Step 2.
Pediatric Rash Step 2: Evidence of Badness?
- Naturally, our default is always to be concerned for badness and, thus, we need to look for evidence of serious, systemic illness first.
- Finding any of the following characteristics does not necessarily define “badness” as being present, but it should make you think more carefully of that possibility.
- Actively look for:
- Is this ITP?
- Are these petechiae associated with coughing/vomiting and above the nipple line or are they below the nipple line and concerning for Meningococcemia?
- Does this fit the “illness script” of HSP?
- Platelet disorders? TTP?
- Unfortunately, must also consider Abuse.
- Chickenpox (yes, it is still around)
- Burns to Bullous Impetigo. Lots to consider.
- Target Lesions
- Erythema Multiforme?
- Spectrum of Stevens Johnson Syndrome / Toxic Epidermal Necrolysis?
- Erythema Marginatum concerning for Rheumatic Fever?
- If none of these characteristics exist, move to Step 2.
Pediatric Rash Step 2: Look at the Mucous Membranes Again!
- Let’s be honest, looking in a kid’s mouth can be challenging, but this step is very important!
- For instance, ITP with Wet Purpura (mucous membrane involvement) may be a clue to greater risk of spontaneous bleeding.
- Certainly, finding Koplick’s Spots would alter your plans.
- Even finding herpangina or gingivostomatits may impact your plan!
- While wiping the sweat off of your brow and allowing the parent’s muscle fatigue to resolve, move onward to step 3.
Pediatric Rash Step 3: Look for “Common Pediatric Rashes”
- Now, you get to demonstrate your Pediatric Rash Prowess by looking for those “classic” pediatric skin eruptions.
- If Steps 1-3 have not lead to a diagnosis or a high level of concern, then move onward to step 4.
Pediatric Rash Step 4: Admit You Aren’t Sure
- This is the hardest part… admitting to the family that you are not sure what the cause of the rash is can be challenging.
- We are not admitting defeat… we are appropriately avoiding the addition of an incorrect “label” (diagnosis) to the patient.
- Announce your reassurance in the lack of the concerning characteristics…
- Acknowledge that rashes often evolve over time…
- In the next several hours to days, your ability to make a more accurate diagnosis may change.
- Give good anticipatory guidance on what specific things they need to monitor for and encourage repeat evaluation in the next 12-24 hours.
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