Patients’ families often present to us requesting “bloodwork” to make sure that the child is not “sick” or to tell them “what’s wrong.” While we all know that no lab can be used to proclaim complete certainty of a patient’s health or to make a definitive diagnosis on its own, often we perpetuate the myth by ordering labs that do not necessarily direct our actions. By now, most of you know of my disdain for the ubiquitous WBC count (The Last Bastion of the Intellectually Destitute – Amal Mattu), but there is another often ordered test that may also fall into that category — the Lactate Level.
The Lactate Level has grown in popularity over the past decade, particularly in the Adult EDs. Certainly, there is literature that supports its utility with respect to evaluation of SEPSIS and trauma, but this often becomes extrapolated to all patients who “may be sick” as a means to find the covertly ill. This approach (often in a “shotgun” fashion) has steadily crept into the Pediatric EDs as well. What is the known utility of Lactate Level in children? [Thank you for inspiring the question].
Lactate Level – Basic BioChem
- Just in case you don’t recall BioChem class as well as you used to…
- During Glycolysis glucose is converted into Pyruvate.
- Through AEROBIC metabolism, pyruvate is used to generate 2 Acetyl-CoA and eventually many ATPs, H2O, and CO2 (remember the Krebs cycle?).
- When there is not enough Oxygen around (ANAEROBIC metabolism), then pyruvate is converted into Lactate.
- Lactate can be converted back to pyruvate once the oxygen deficit has been corrected.
- Well that was a fun walk down memory lane.
- With this in mind, elevated lactate levels would potentially reflect tissue oxygen deficit.
- Under normal conditions, lactate is rapidly cleared by the liver, with some assistance from the kidneys. (Anderson, 2013)
- There is no standardized levels:
- Most studies use cutoff values of 2.0 to 2.5 mmol/L.
- Many define “High” as a Lactate level > 4.0 mmol/L. (Anderson, 2013)
Lactate Level – Some Causes of Lactate Elevation
Most often elevated Lactate Levels conjure thoughts of tissue hypoperfusion with diminished access to oxygen (SHOCK), but there are others causes to consider. (Anderson, 2013)
- Global ischemia (SHOCK)
- Regional ischemia (ex, mesenteric ischemia, burns, trauma, compartment syndrome)
- High Metabolic States (ex, seizures, heavy exercise, increased work of breathing)
- Drugs (ex, Metformin, epinephrine, propofol, acetominophen, beta-2-agonists)
- Toxins (ex, Cocaine, Cyanide, Carbon monoxide, alcohols)
- Liver Disease (can’t clear the lactate)
- Diabetic Ketoacidosis
- Thiamine Deficiency (w/o thiamine, anaerobic metabolism predominates)
- Inborn Errors of Metabolism and Mitochondrial Diseases
Lactate Level – Elevation in Kids
- In the PICU:
- Studies of SEPSIS have shown increased mortality in the setting of elevated lactate levels. (Jat, 2011)
- Monitoring serial lactate levels in patients following surgery for congenital heart disease can help discriminate patients at high risk. (Schumacher, 2014; Agrawal, 2012)
- Poor lactate clearance (< 30% at 6 hours) has been associated with increased risk of mortality. (Munde, 2012)
- High lactate level upon admission to the PICU is associated with in-hospital mortality. (Bai, 2014)
- In the ED:
- High lactate levels can be useful to help “rule-in” severe bacterial infection in children in the ED. (Vorwek, 2011)
- High lactate levels identify a population at higher risk for severe outcomes amongst the kids with SIRS in the Peds ED. (Scott, 2012)
- After Return of Spontaneous Circulation following a resuscitation, higher lactate levels are associated with higher likelihood of death, although don’t predict outcomes. (Topjian, 2013)
- Elevated lactate levels obtained in pediatric trauma patients during prehospital transport are associated with increased need for critical care. (Shah, 2013)
Lactate Level – Did it Help You?
- Thus far, we see that, like in adults, an elevated lactate can help identify those patients who are potentially sicker than others, although not perfectly.
- One issue is that, often, an astute clinician would generate a similar assessment of clinical severity. (Scott, 2012)
- Another issue is that, when obtained in the “shotgun” approach of obtaining labs, often the confounders (see above) are not taken into account.
- It is only helpful if it alerts you to severe illness presenting subtly or helps direct your resuscitation efforts… which, again, require the astute clinician to determine.
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Parental concerns, appropriately, drive a lot of the traffic to our Emergency Departments. Managing concerns and expectations is part of the art of what we do. When a child develops Rectal Prolapse, there are often a lot of concerns, but it is important to keep some basic issues in mind.
Rectal Prolapse: Basics
- Generally is a benign condition.
- Often get sent to surgeons and GI specialists, but rarely require more than conservative management.
- ~90% of kids 9 months to 3 years will not need additional therapy.
- Most common under age 4 years! Highest Incidence is <1 year of age.
- The prognosis is more ominous in kids who develop it after age 4 years.
- Mechanically, it is an intussusception of the rectum.
- Classification of Prolapse: (Siafakas, 1999)
- Mucosal Prolapse – Mucosa only; Generally < 2cm; Has radial folds
- Complete Prolapse – Full Thickness; > 2cm, Has various Degrees/Severities based on length and whether the mucocutaneous junction is involved; Has circular folds
- Third Degree actually is internal and does not pass through the anus.
Rectal Prolapse: Why it Happens
- More vertical course of the rectum along the sacrum.
- Low position of the rectum and increased mobility of the sigmoid colon.
- Lack of support by the levator ani muscle.
Associated Conditions (Siafakas, 1999)
- Increased intra-abdominal pressure
- Chronic straining (constipation)
- Attempts at toilet training at a developmentally inappropriate time.
- Protracted coughing spells (Pertussis?)
- Excessive vomiting
- Diarrheal Illness
- Acute or Chronic
- Infectious diarrhea (ex, shigella, C.Diff)
- Malaborption (ex, celiac, pancreatic insufficiency)
- Cystic Fibrosis accounts for ~11% of rectal prolapse in the Western World, likely from multiple mechanisms.
- Rectal Prolapse may be the presenting sign of Cystic Fibrosis in up to 33% of patients before other symptoms!
- Parasitic Disease (ex, whipworms)
- Neoplastic Disease (ex, polyps)
- Worldwide, likely most common condition associated with rectal prolapse.
- Due to loss of fat leading to less perirectal support.
- Neurologic Disorders (ex, Myelomeningoceles)
- Misc: Congenital Hypothyroidism, Ehlers-Danlos Syndrome, Hirschsrpung’s.
Rectal Prolapse: Management
- Most often the child with rectal prolapse will spontaneously reduce prior to your exam.
- If it is still present, consider a few entities prior to simply reducing it. (Siafakas, 1999)
- Ileocecal Intussusception
- Can actually protrude from the rectum.
- Distinguished from rectal prolapse by:
- Child appears clinically ill and
- Examiner’s finger can pass between prolapsed tissue and the anal sphincter.
- Rectal Polyp that has Prolapsed
- May appear during defecation and then reduce.
- Does not involve the entire anal circumference.
- Reduce it!
- If it still is prolapsed, reduce it with steady pressure .
- If it has been prolapsed for awhile, there may be swelling.
- Firm, steady pressure with fingertips may be required for several minutes.
- Many will talk about applying sugar to help lessen the edema, but I have not found any definitive literature on this.
- Ask yourself why it happened!
- See the above issues and consider whether any are the cause.
- Unexplained rectal prolapse deserves follow-up for possible cystic fibrosis testing.
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Numerous trauma related topics have been covered within the Morsels (ex, pneumothorax, c-spine injury, aortic trauma, head trauma), but, unfortunately, not all trauma that children suffer is accidental. Non-accidental Trauma / Child Abuse is a prevalent concern for us as we care for children. We are all acutely aware of the devastating injuries that are associated with non-accidental trauma. This Morsel is meant to remind us that once we find one injury, don’t stop looking… as the risk for another is still present. This is particularly true with respect to an occult abusive abdominal injury!
Abusive Abdominal Injury Kills
- Relatively rare (0.5-11% of cases), but is the 2nd leading cause of child abuse associate mortality (head injury is #1).
- Mortality rates as high as 45%.
- Estimated that abdominal trauma contributes ~50% of abusive fatalities. (Maguire, 2013)
- The young patient has several anatomic factors that make him/her more susceptible to blunt abdominal trauma.
- Less protective covering.
- Thinner abdominal muscles and less fat.
- Less protective ribs.
- The compliant ribs do not dissipate force.
- That transmitted force now is absorbed by the underlying organs and structures.
- More exposed solid organs.
- The diaphragm is more horizontal compared to older patients.
- The liver and spleen are, thus, more anterior and less protected by rib cage.
- All abdominal organs are at risk for injury. (Maguire, 2013)
- Solid Organs
- Liver injury is the most commonly seen in hospitalized patients (64%).
- Abuse is reported as being the 2nd or 3rd most common cause of hepatic injury in children, after MVCs.
- Kidney (19% of hospitalizations)
- Hollow Organs (12% of hospitalizations)
- Duodenal perforation, transection, and hematoma have been documented.
- Often present in delayed fashion (as you’d expect).
- Duodenal perforation is so rare in kids < 5 years of age, that if found, abuse should be suspected.
- >25% of ALL abdominal trauma in children < 1 year of age has been shown to be due to abuse. (Lane, 2012)
- Infants have the highest rates for abusive abdominal trauma (17.7 cases / million in 2006).
- Toddlers also have high rates.
- Infants and Toddlers cannot communicate well so abdominal complaints can be missed.
- Abdominal trauma sustained by an infant or toddler should make us consider the possibility of abuse.
It Is Often Occult
- It is estimated that 6-8% of abused children will have abdominal injury without overt signs.
- The history can be purposefully deceiving (alternating or evasive stories) and the child cannot communicate well to relay clues.
- The exam can be deceiving.
- Difficult to detect because of few external signs.
- The compliant rib cage will not often fracture.
- External bruising is not often present - as few as 12% will have it. (Ledbetter, 1988)
- If there are abnormal findings (tenderness, distention, bruising) then the likelihood of finding abdominal injury is 5 fold greater!
- Lab Tests can be deceiving.
- Similar to accidental pediatric abdominal trauma, the utility of a normal set of LFTs and Lipase is low.
- Abnormal values, however, do warrant imaging (with a CT scan… U/S won’t be good enough as kids are less likely to have free fluid with their intra-abdominal injuries).
- The high mortality associated with this condition demands our respect, despite the fact that it is rare and may be difficult to detect.
- First of all, stay vigilant, especially AFTER you have already found one injury.
- Great job catching that rib fracture (which is definitely concerning for abuse in young kids), but don’t get complacent.
- Abdominal injuries were often found with other associated injuries.
- Like with other trauma, once you find one injury, look harder for the other one.
- Personally, I have a low threshold for getting LFTs and Lipase and U/A in a child that has a defined abusive injury.
- But know that normal labs do not rule out the presence of an abdominal injury.
- They also do not look at possible splenic, adrenal, or small bowel injury.
- Clinical Vigilance and repeat exams trump labs.
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Every so often you encounter a patient that has a finding that catches you by surprise. Like having air in places that should not have air in them. We have discussed spontaneous pneumothorax and traumatic pneumothorax in children as well as how to detect pneumothorax in neonates and how to treat a pneumothorax, but what about pneumomediastinum? As you try to resist the urge to say “D’Oh!” let us consider Pneumomediastinum!
- Pain – Chest Pain, Neck Pain, Throat Pain
- Hoarseness, Stridor, Cough
- Globus Pharyngeus – persistent or intermittent, non-painful sensation of swelling or foreign body in throat.
- Dyspnea, Choking
- Facial and/or Neck Swelling
- Imaging Modality
- Lateral Neck Soft Tissue plain film is more sensitive than PA CXR (95.2% vs 89.1%). (Wang, 2013)
- CT is certainly more sensitive than plain radiographs, but would not be a reasonable screening strategy.
- Primary Pneumomediastinum = presence of air within the mediastinum with NO obvious precipitating event.
- Of cases of pneumomediastinum one study found ~50% were Spontaneous Primary Pneumomediastinum. (Wong, 2013)
- Secondary Pneumomediastinum = Pneumomediastinum is present due to a defined etiology:
- Spontaneous (Wong, 2013)
- Asthma Exacerbation – ~17%
- Pneumonia or Lower Respiratory Tract Infection – ~13%
- Choking Events / Foreign Body Aspiration – ~12%
- Viral Illness / Cough / Croup – ~3%
- Spontaneous esophageal or bronchial rupture are very rare causes of pneumomediastinum in kids.
- Traumatic (Pryor, 2011)
- Relatively uncommon after trauma to neck, thorax, or abdomen.
- Can be associated with life-threatening tracheobronchial, esophageal, or vascular injuries.
- All of the patients who had significant injury to trachea/bronchus, esophagus, or vascular structures were identified on CXR.
- Most common associated injuries found with complicated pneumomediastinum were:
- Less common to see significant mediastinal injuries in children than adults.
Age Matters with Pneumomediastinum
- In children less than 6 years of age, spontaneous primary pneumomediastinum is very rare. (Wang, 2013)
- For young kids, look more diligently for a cause of the pneumomediastinum.
- Asthma exacerbation is a common cause.
- Keep Foreign Bodies on the DDx as they can be tricky. (Hu, 2012)
- With a history of choking / gagging, have a low threshold to obtain bronchoscopy / esophagoscopy.
- Children older than 6 can have spontaneous primary pneumomedisastinum.
- Base evaluation of it on the history and presentation.
- Naturally, the question is what needs to be done once you have diagnosed the pneumomediastinum.
- When do you need to look for potential causes of Secondary Pneumomediastinum?
- Here is a proposed strategy (Wang, 2013):
- Manage conservatively if:
- Presents with an asthma exacerbation,
- Presents with recent onset of fever,
- Presents with vigorous cough,
- Presents with NO choking episodes.
- Consider further investigations as indicated (ex, bronchoscopy, esophagoscopy, Upper GI/Swallow study, Chest CT) if:
- Presents after a catastrophic event,
- Presents after a choking episode,
- Presents with dysfunctional swallowing,
- Presents after trauma and has clinical evidence of aerodigestive injury. (Neal, 2009)
- Consider Age
- Have lower threshold for further evaluation in the younger child (as they are less likely to have spontaneous primary pneumomediastinum.
- Extensive diagnostic evaluations in uncomplicated spontaneous pneumomediastinum in adolescents is often unnecessary.
- Consider Clinical Course
- Kids with isolated pneumomediastinum, no other abnormalities on CXR, and low risk mechanism (if traumatic) are at at low risk for tracheobronchial, esophageal, or vascular injuries, so observation alone would be appropriate; however, if clinically worsens, than reconsider other potential problems. (Pryor, 2011)
- Not all that wheezes is asthma… Foreign Bodies can be difficult to diagnose, so reconsider this potential if patient does not respond to therapy as you’d expect.
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Certainly, the PedEM Morsels promote a need for vigilance! Vigilance is required to find those troublesome conditions that masquerade as benign conditions (see Inborn Errors of Metabolism, Meningococcemia, and Neonatal Seizures for a few examples). Vigilance, however, is not just useful when considering a diagnosis: it is also necessary when discussing anticipatory guidance and the medical plan. Medication Errors are a significant problem that a little preemptive action can help avoid.
Giving Medicine is Tricky
- Medication errors are a common cause of adverse events and are more often seen in pediatric patients than adults.
- Kids’ various sizes (both in weight and body surface area) and metabolic rates create challenges.
- The fact many pediatric medications are liquid creates another challenge.
- Even the experts are susceptible to error.
- The chaotic environment of the ED, certainly enhances the chances of error (Leape, 1991).
- Protective systems can help decrease medication errors in the hospital (Damhoff, 2014).
- Some examples:
- Electronic ordering systems
- Avoiding often confused units of measure
- Using weight-based dosing
- Pediatric-specific pharmacy
- Pharmacist in the ED
- Still no system is fool-proof and requires vigilance.
- If the experts are susceptible to error, how can we expect parents and care-givers to get it right?
- An estimated 71,224 ED visits per year were made for unintentional overdose in children (Schillie, 2009).
- ~34% were for over-the-counter (OTC) medications
- ~14% were for medication errors / misuse
- The odds are stacked against families!
- Parents may not know the child’s specific and current weight at the time of medication administration.
- Health Literacy and Numerical Literacy varies greatly amongst all patients and impacts interpretation of medication instructions (Bailey, 2009).
- OTC medications may exist in various concentrations complicating administration.
- It has been found that OTC medications often contain variable and inconsistent dosing directions (Yin, 2010).
- OTC measuring devices have also been found to be inaccurate, inconsistent, and confusing.
- There are a variety of measuring devices, often not standardized.
- Measuring cups, syringes, droppers, “teaspoons,” etc.
- Medicine cups have been shown to be related to a high occurrence of dosing errors (Tanner, 2014).
A Teaspoon Should NOT Be For Medicine
- Parents who use teaspoon or tablespoon units had TWICE the odds of making an error! (Yin, Pediatrics 2014)
- While a teaspoon is a unit of measure, it also often confused with the household utensil, which may vary greatly in actual size.
- Abbreviations can be confusing: “tsp” can be misinterpreted as “tbsp” and vice versa.
- Advocate for milliliters as the unit of measure.
Educate and Simulate
- We all know that simulation strategies have benefited our processes of medical education… hands-on helps the memory.
- Use this strategy for patients and parents as well.
- The use of both education and demonstration have been found to be more effective at reducing liquid medication dosing errors (Yin, Academic Pediatrics 2014).
- Establish systems in your ED that encourage this process to help avoid preventable medication errors.
- Use a oral syringe with milliliter measurements.
- Discuss the appropriate dose and frequency of the medication.
- SHOW the family how to fill the syringe to the appropriate dose. Ensure that this is not ambiguous.
- Have the family teach/show you how they will administer the medication at home.
- Discharge with clear instructions illustrating the key points again.
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Full Disclosure: I am the proud product of Combined Emergency Medicine and Pediatric training (thank you mentors Mattu, Rogers, Winters, Carraccio et al at U of Maryland). As such, I worked nearly equal amounts of time in the Emergency Department (caring for kids and adults) as I did in my Pediatric clinic over 5 years of residency. That being said, there is a reason I do Emergency Medicine… I could not stand going through the assessment of kids’ Developmental Milestones in the clinic! Certainly it is important… but not for me in the ED… right? Actually, there are many aspects of Developmental Milestones that can be useful to the vigilant clinician in the Pediatric ED.
Not Trying to Make You a PCP
- Many of us in the ED have violent expulsion of gastric contents at the mere mention of considering any topic that is related to primary care.
- While that is understandable (much like, we would not expect or want a Primary Care Physician to be expert in the EM realm), it is still useful to know some topics that bridge both worlds.
- Some EM clinicians are serving as the only access to care a patient has… and need to know some primary care issues.
- Almost 30% of 6- to 36-month-old children presenting to an urban PED without prior developmental concerns screened positive for possible delay. (Grossman, 2010)
- Prescription of Controller Medications for Asthma is a good example of this (see Twitter conversation for additional thoughts).
- Childhood Development is another topic that is not typically placed within the EM realm.
- A full development assessment is actually beyond what can be done in a typical pediatrician’s office schedule.
- Knowledge of basic developmental milestones, however, can help detect important aberrations that warrant further assessment.
- This is particularly true with respect to the very young, as this can have implications in their neurologic exam.
- This is similar to how knowledge of typical growth estimates can help you manage a child in the ED.
Developmental Milestones Basics
- Classically, childhood developmental milestones are divided into different domains:
- Motor delays may be the first and most obvious sign of a global developmental disorder (Nortiz, 2013).
- Not every kid develops at the same rate, but they generally should progress through the expected milestones in order.
- Two really good resources for Developmental Milestones are:
Typical Infant Developmental Milestones
- Again, kids achieve milestones are various paces… so these are just estimates… but can help define marked abnormalities.
- Head Posture / Control
- 8 weeks – can hold head up while prone
- 12 weeks – has some head lag when being pulled from supine position
- 20 weeks – no head lag
- 6 months – complete head control
- Fine Motor
- 2 months – grasps offered item
- 4 months – reaches for objects. Brings hands to mouth (now we are in trouble)
- 6 months – transfers objects form one hand to another
- Gross Motor
- 2 months – begins to push up while prone
- 4 months – able to roll from tummy to back (essentially pushes self over). Bears weight on legs when feet are on a surface. Sits with curved spine.
- 6 months – able to roll from back to tummy. Can sit without support.
- 9 months – sits with straight spine.
- 18 months – should sit, stand, and walk independently.
- Social / Language
- 2 months – attempts to look at parents. Smiles. Coos.
- 4 months – smiles at people spontaneously.
- 6 months – indicates desire to be picked up. Knows familiar faces and recognizes when someone is a stranger. Babbles.
- 9 months – the height of separation anxiety! Plays “peek-a-boo” and waves “bye-bye.” Understands “No.”
- 12 months – knows one – two words.
- 18 months – knows three – six words (body parts often).
- 24 months – uses two word phrases.
- 36 months – uses three word sentences.
- Language and Social milestones are closely tied with Cognitive milestones, particularly early on.
- 2 months – regards faces, has differential coos and cries and can indicate wants.
- 4 months – reaches for objects, uses hands and eyes together.
- 6 months – shows curiosity. Uses visual and oral exploration of environment.
- 9 months – has object permanence (looks for item when it is hidden). Learns interactive games.
- 12 months – can follow simple instructions. Bangs objects together.
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