Infectious diseases are commonly considered when dealing with pediatric patients. We have covered topics in this realm numerous times (I believe that this would be the 64th Morsel in the ID category). One of the more prevalent considerations is pediatric pneumonia.
Previously, we have discussed the issues that surround making the diagnosis of pneumonia. We have also touched on some complications and interesting pediatric findings. Additionally, we covered the basic recommended therapies. While the recommendations are for narrow spectrum antibiotics as 1st line (penicillin), many of us still see a lot of broad spectrum antibiotics being used, particularly for those who we admit to the hospital. While it may be fun to say “Cef-Kill-it-All,” is that the right answer for community acquired pneumonia in children?
Community Acquired 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!
Penicillin Works Great!
- Several recent studies (see references) support the fact that narrow spectrum antibiotics for community acquired pneumonia is an effective 1st line option.
- Penicillin/Ampicillin/Amoxicillin treat uncomplicated community acquired pneumonia as effectively as broad spectrum agents.
- Broad spectrum antibiotics also work, but increase risk for developing resistant organisms! (Oh, Darwin!)
- S. pneumoniae is the primary target.
- Narrow spectrum penicillins provide appropriate coverage for this bug!
- S. pneumoniae can become resistant to penicillin; however, this is generally a more important consideration for CNS infections (not pneumonia).
- This is true even for those that you are admitting to the hospital!
- The adage “Go Big or Go Home,” does not apply to the selection of 1st line antibiotics for community acquired pneumonia!
- Even if your patient is not going home… you still don’t need to use the “big gun.”
- If they are not responding within 48 hours, then the decision to change therapies can be made.
The Therapeutic Recommendations
- In 2011, the Pediatric Infectious Diseases Society and the Infectious Disease Society of America published guidelines for management of community acquired pneumonia.
- Pre-School Age and Fully Immunized
- 1st Line Therapy – Penicillin or Amoxicillin.
- Honestly, the majority are viral pathogens.
- School Age and Fully Immunized
- 1st line therapy = Penicillin or Amoxicillin.
- Consider Atypical Pathogens
- Fully Immunized Infants – School Aged Kids
- If local epidemiologic data does not show high level of penicillin resistance, then
- Ampicillin or Penicillin G
- If local epidemiologic data shows high level of penicillin resistance, then
- 3rd Generation Cephalosporin (ceftriaxone or cefotaxime)
- Consider Macrolide for Atypical Pathogens
- Not Fully Immunized or with Life-Threatening Infections (ex, Empyema)
- 3rd Generation Cephalosporin (ceftriaxone or cefotaxime)
- Vancomycin has not been shown to be more effective for empiric therapy in North America.
- Vancomycin or Clindamycin should be consider if infection is consistent with S. aureus.
Moral of the Morsel
Obviously, selection of antibiotics for patients needs to be tailored to the specific individual patient (are they immunocompromised, do they have prior history of resistant organisms, are they not vaccinated, etc); however, the decision to admit the patient does not then mandate that the patient receive broad spectrum antibiotics. Good old fashion penicillins are appropriate initial selections for the patient with uncomplicated community acquired pneumonia – whether admitted or discharged.
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. 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):e25-76. PMID: 21880587
. [PubMed] [Read by QxMD]
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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Last week’s Morsel discussed patellar dislocations and mentioned the use of nitrous oxide to assist with the reduction. Many of you had great feedback on other pain management options (thank you!). Obviously, the management of pain is one of our primary objectives and the science and art of it does not lend itself to a simple, single option. Fortunately, we have many options that can be appropriately tailored to our patients.
Recently, a colleague and friend, Dr. James Homme, delivered a brilliant presentation on Ketamine for Analgesia at the ACEP/AAP Advanced Pediatric Emergency Medicine Assembly and proclaimed “To know ketamine, is to love ketamine.”
We have covered Ketamine’s use for Delayed Sequence Intubation and for the treatment of Hypercyanotic Spells and the team at Don’tForgetTheBubbles.com just covered it’s use for Conscious / Procedural Sedation. Now, let’s explore the next frontier for Ketamine usage: Analgesia!
The Problem with Brief Painful Procedures…
- Many of the procedures that we need to perform in the Emergency Department do not require a prolonged time.
- Incision and drainage, uncomplicated joint reductions, wound cleansing / debridement, uncomplicated laceration repair are all great examples of procedures that often do not require more than a few minutes of actual procedure time.
- The problem with these procedures is that they are still painful and scarey.
- This creates a difficult to solve risk : benefit ratio equation.
- Risk of full conscious / procedural sedation
- Risk of suboptimal pain and anxiety control
- Risk of physical restraint
- Unfortunately, the equation is often solved in a manner that inadequately controls the child’s discomfort in favor of being expedient.
There is No Perfect Rx, But Ketamine is Close…
- The World Health Organization has characterized Ketamine as a “core medication for basic healthcare systems.”
- While those of us in Ivory Towers can debate, it is recommended for systems with far fewer resources.
- The US Defense Health Board called Ketamine “a new alternative to conventional battlefield analgesia” in 2012.
- Ketamine is ideal for pain management in an austere environment.
- Safe and effective.
- Rapid onset.
- No respiratory depression.
- Requires little (if any) monitoring.
- Our EDs are like luxury hotels compared to the austere regions it is being used in.
- Referred to morphine as “the slipping gold standard.”
- The world’s literature (see references) notes Ketamine is effective at reducing pain quickly (usually by 5 minutes).
- The first publication showing Ketamine as being effective as an analgesic was in 1971.
- Ketamine used at subdissociative doses worked better than merperidine for reducing pain response.
- Since then we have become very comfortable with it as a medication for conscious / procedural sedation.
- It’s association with PCP has likely affected its usage as an analgesic, however.
Analgesic Dosages: 0.1 – 0.3 mg/kg IV; 0.5 – 1 mg/kg IM
Partial Dissociation: 0.4 – 0.8 mg/kg IV
Dissociation Dosages: 1 – 2 mg/kg IV; 2 – 4 mg/kg IM
Barriers to Ketamine’s Use
- Institutional labeling
- If your hospital has labeled it as a medication to be used for sedation purposes, you will likely met resistance to giving it for analgesia without filling out 1,000 pages of conscious sedation paperwork.
- Perhaps you can use the references below to change that.
- Certainly we use other medications for various applications (opioids, benzodiazepines, etc).
- Myths about head injury
- Fear of Emergence Reaction
- This is actually a rare event for the group that receives subdissociative doses of Ketamine.
Potential Therapeutic Groups
- The awake patient who needs a brief painful procedure (5-10 min).
- The patient with chronic pain on opioids presenting with intractable pain (ex, Sickle Cell Pain Crisis).
- The patient in whom pain is associated with emotional distress.
- Ketamine not only controls pain, but it also makes people seem to be indifferent to it.
- Ketamine is also being looked at for treatment of depression.
So, while you might not be using Ketamine for Analgesia during your next shift for that I+D, maybe in the very near future you will be.
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We all like to feel like we can heal with our hands. For this reason, simple reductions are sometimes welcome complaints in your ED that is filled with copious rhinorrhea and voluminous emesis. We have discussed feeling like Mr. Miyagi during reductions of Nursemaid Elbows. Another reduction that can make you feel similarly is the Patellar Dislocation, but before you bow as you exit the exam room, make sure that you aren’t being too cavalier.
Patellar Dislocation Basics
- Acute patellar dislocation is a common knee injury.
- Most often occurs in teenagers.
- Most frequently associated with sports or physical activities.
- Often seen when the femur rotates internally, the tibia rotates externally, and the foot is fixed.
Some Important Anatomy
- The Medial Patellofemoral Ligament (MPFL)
- Thin transverse band that extends from the femur to the medial aspect of the patella.
- The MPFL is the primary ligamentous restraint for the patella.
- It provides 50-60% of the restraining force.
- The MPFL is ruptured in 94-100% of patients with acute patellar dislocation.
- Repeat dislocation is dependent upon the MPFL injury rather than other predisposing factors (some listed below):
- Lateral patellar tilt
- Patella alta (abnormally high patella)
- Trochlear dysplasia
- Increased Q angle
- Genu Valgum
- Vastus Medialis Muscle hypoplasia
- Increased femoral anteversion
- Congenital conditions that lead to ligament laxity
Reduction of Patellar Dislocation
- Flex the Hip to relax the Quads.
- Apply medial pressure to the lateral edge of the dislocated patella.
- While continuing to apply medial pressure, extend the knee.
- See friend and colleague,
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For Emergency Physicians, neonatal “issues” often fall into one of two categories: 1) terrible, life-threatening disasters (ex, Necrotizing Enterocolitis, HSV, Congenital Heart Disease) and (2) I have no clue what that is, but it seems like your Primary Care Provider can help you with that (ex, feeding problems, rashes). While those two classifications may be appropriate for most cases, neonates are tricky and often the boundaries between those two groups are blurred. Is that neonates vomiting typical spit up, or a sign of Pyloric Stenosis or Intussusception or Malrotation?
Additionally, neonates can also present with unique problems that are not commonly encountered, but are necessary for us to be familiar with (ex, Umbilical Cord Issues). One interesting problem that might seem to be an easy issue to simple refer, but may actually benefit from us knowing a little more about it is Natal and Neonatal Teeth. If families are worried about fevers, they sure are going to be worried about a tooth growing in their newly born child!
What is Typical?
- Normally, teeth begin to erupt around 6 months of age.
- Delayed tooth eruption may be due to a medical problem.
- Hypothyroidism, Hypopituitarism
- Down Syndrome
- Dental / Mouth infections
- Refer a child who has not developed a tooth by 18 months to a dentist.
- Permanent teeth typically begin to erupt @ 5-7 years of age.
- Typical pattern of eruption: central incisors, lateral incisors, 1st molars, premolars, canines, 2nd molars, and 3rd Molars (although not everyone develops Wisdom Teeth).
Neonates with Teeth!
- Teeth that are present at birth are called Natal Teeth.
- Reported to be 3 times more common than Neonatal Teeth.
- Teeth that develop within the first 30 days of life are called Neonatal Teeth.
- Incidence ranges between 1:716 and 1:30,000.
- Likely to be more on the rare side than the common.
- Most often these teeth are the mandibular insisors (85%).
- Often they occur in pairs.
- >90% of the time these teeth are part of the normal complement of primary teeth.
- 1-10% of the time the teeth are supernumerary.
- Natal/Neonatal Teeth may be normal in size, shape, and color; however, usually are not.
Categories of Natal / Neonatal Teeth
- Category 1 – Shell-like crown that is loosely attached – NO ROOT
- Category 2 – Solid crown that is loosely attached – Little or NO ROOT
- Category 3 – Incisal edge of the crown just erupted through mucosa.
- Category 4 – Palpable with mucosa swelling, but not erupted.
Complications: Why We Care
- Feeding difficulties leading to malnutrition and dehydration.
- Loss of tooth with possible ingestion or aspiration.
- Often listed as complication, but no actual reports in literature.
- Riga-Fede Disease: ulceration on the tongue caused by the tooth.
- Possible dental injections (enamel is often absent).
- Breast irritation for the breast-feeding mother.
- For the EM doc… our role will be mostly one of education and referral.
- X-Rays are helpful to determine if the teeth are a part of the normal compliment of teeth or whether they are “extra” / supernumerary.
- Generally safe to refer to pediatric dentist.
- Extraction is usually able to be accomplished with forceps or even fingers.
- Extraction favored for:
- Very Loose
- Adversely effecting feeding and nutrition
- Association with trauma to local structures (ex, Riga-Fede Disease)
- Associated with cleft lop/palate
- Generally safe to wait to extract them, if necessary, until after 10 days of age – allows for endogenous production of Vit K.
- If you must extract it, ensure that the Vit K was already administered.
- One-third to two-thirds of natal teeth fall out during 1st year of life.
- Those are still present at 4 months of age typically have good prognosis.
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This week I had the pleasure of working with my dear colleagues during the Pediatric Procedure Course at ACEP/AAP Advanced Pediatric Assembly. We covered numerous important procedures, but one that deserves mentioning here is the use of Pigtail Catheters for pneumothorax and pleural fluid drainage. We have previous discussed the value of Pigtail Catheters for the treatment of Spontaneous Pneumothorax and Traumatic Pneumothorax. Obviously, every decision we make comes with risks and benefits as well as pros and cons. The choice of a device to drain air or fluid from the pleural cavity certainly shouldn’t be a snap decision.
Large Caliber vs Small Caliber
Large Caliber Chest Tubes
- Can drain VISCOUS fluid
- Resist becoming obstructed or kinked.
- Occupy large space in the child’s narrow intercostal space.
- Potential risk for damage to chest wall structures (neurovascular bundle, muscles, etc).
- Difficult for patient to be mobile with while it is inserted.
Small Caliber Pigtail Catheters
- Shown to lead to less discomfort.
- Less hindrance to ambulation and mobility.
- Proven to be as effective as larger bore chest tubes.
- Can lead to shorter hospital days.
- Can be mechanically kinked.
- Can be occluded by viscous or turbid fluid.
Open vs Seldinger
Open Technique for Large Caliber Chest Tubes
- Able to clearly define that you are in the appropriate location.
- You can feel the lung parenchyma and know that you aren’t inserting tube into the liver or spleen!
- Relatively straight forward procedure.
- More invasive.
- More traumatic.
- More painful.
- Produces larger scars.
Seldinger Technique for Small Caliber Pigtail Catheters
- Less Invasive.
- Less traumatic.
- Less likely to damage surrounding structures.
- Smaller region involved and pain can be more reasonably controlled.
- Less scarring.
- Seldinger technique doesn’t allow for easy confirmation of appropriate placement.
- Some reports of organ laceration.
- More steps to the procedure.
- Requires more specialized equipment.
- Consider what it is that you need to drain.
- If it is air or acute blood, use a pigtail.
- If it is expected to be viscous, consider a small caliber thoracostomy tube.
- One study actually showed that empyema can successfully be drained by pigtail catheter and recommends starting with pigtail first.
- If considering a traditional thoracostomy tube… reconsider it… and reconsider it again… Pigtail likely will be better.
- Use Ultrasound!
- Improve your vision and define your anatomy with ultrasound.
- There is no reason to guess!
- Reduce complications by paying attention to anatomic landmarks.
- Aim High!
- Some experts advocate for inserting Pigtail Catheters above the 6th intercostal space to avoid subdiaphragmatic catheter placement.
- Be Safe!
- Use a J-tipped (flexible tipped) guidewire with your Pigtail Catheter, rather than a straight wire.
- Don’t Be Cruel!
- Consider the advantages of having the patient more comfortable and able to ambulate earlier.
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Accidental injury (Trauma) leads to more pediatric deaths than ALL OTHER CAUSES COMBINED! Fortunately, unlike in adults, thoracic trauma is less common in kids (only 4-6% of pediatric traumas). Unfortunately, it is the SECOND leading cause of death after blunt trauma (Head Injury is #1). One would think that Aortic Trauma would need to be a major consideration… but, does it?
Kids are Flexible!
- Being flexible can be very helpful … it can also cause problems.
- Cons of Flexibility with respect to Thoracic Trauma:
- Chest wall is very compliant and won’t dissipate impact force – leads to less rib Fx, but more pulmonary contusion.
- Mobile mediastinum can be more influenced by intra-thoracic pressures and potentially compromise Preload more readily.
- Pros of Flexibility with respect to Thoracic Trauma:
- The mediastinum is mobile… not tethered down by a fibrous ligamentous arteriosum… Aorta not as likely to be torn.
Aortic Trauma is Rare
- Fortunately it is Rare: ~0.1% of pediatric trauma registry cases had blunt aortic injury.
- It is good to be young and flexible.
- Unfortunately, 41% of them died!
- Cannot exclude the diagnosis.
- Look for:
- Apical Cap (blood tracking along left lung apex)
- Widened mediastinum
- Displaced paratracheal stripe to the right
- Displaced left mainstem bronchus inferiorly
- Displaced NG tube toward the right
- Distorted aortic knob
- If you are truly worried about Aortic Trauma, then CT angiogram is the imaging modality of choice.
- Obviously, for such a rare condition, risk of radiation should be weighed.
- Consider the risk factors.
With such a rare disease, it is difficult to announce true risk factors; however, studies have demonstrated common themes amongst those kids who have had aortic trauma (traumatic aortic injury).
- Older Age
- The younger kids are more flexible.
- Teenagers have a more fibrous ligamentous arteriousum… more like adults.
- Multi-Trauma patients with Concomitant Injuries
- Hip Dislocation
- Rib Fractures
- Femur Fractures
- Pelvis Fractures
- Liver/Spleen injuries
- Significant Intracranial injuries.
- High Force
Essentially, these are not the kids that we are debating on whether they need a CT of their Chest. We are looking for extra things to CT (maybe we need to CT the feet).
But, most often the CT of the Chest does not change your management of the Pediatric patient with Thoracic Injury… so don’t go ordering Chest CTs (or Pan CTs) of your pediatric trauma patients reflexively.
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