Pediatric Emergency Playbook

Dogma often dictates routine care. There are times when we have to attend to paradigm shifts. An easy way to save lives?  Just say no to (these) drugs: Codeine Normally metabolized into codeine-6-glucuronide (50-70%) and norcodeine (10-15%).  Codeine, codeine-6-glucuronide, and norcodeine have low affinity for the μ (mu) receptor. However, the most active metabolite of codeine is morphine with 200...

Not all head trauma is minor. Not all minor head trauma is clinically significant.   How can we sort out the overtly ok from the sneakily serious?     Mnemonics for bedside risk stratification of minor pediatric blunt head trauma, based on PECARN studies: [Details in Audio]   Blunt Head Trauma in Children < 2 years of Age     Blunt Head Trauma in Children ≥ 2 years of Age     Image Gently Campaign...

Comfortable with G-tubes, tracheostomies, and VP shunts? Good.  Get ready for the next level: Vagus Nerve Stimulators, Intrathecal Pumps, and Ventricular Assist Devices.   Details in Audio: Vagus Nerve Stimulators For intractable epilepsy; sends retrograde signal up corona radiata Also may be used in: depression, bulimia, Alzheimer, narcolepsy, addiction, and others VNS magnets Are VNS safe in MRI...

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Abdominal pain is common; so are strongly held myths and legends about what is concerning, and what is not.   One of our largest responsibilities in the Emergency Department is sorting out benign from surgical or medical causes of abdominal pain.  Morbidity and mortality varies by age and condition.   Abdominal Surgical Emergencies in Children: A Relative Timeline General Advice Neonate (birth to...

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Myocardial infarction (MI) in children is uncommon, but underdiagnosed.  This is due to two main factors: the etiologies are varied; and the presenting symptoms are "atypical". We need a mental metal detector!  Case examples Congenital Two main presentations of MI due to congenital lesions: novel and known .  The novel presentation is at risk for underdiagnosis, due to its uncommonness and vague,...

Most newborns will have some jaundice.  Most jaundice is benign. So, how can we sort through the various presentations and keep our newborns safe? Pathologic Jaundice When a baby is born with jaundice, it's always bad.  This is pathologic jaundice, and it's almost always caught before the baby goes home.  Think about ABO-incompatbility, G6PD deficiency, Crigler-Najjar, metabolic disturbances, and...

Children the world over are fascinated with what can possibly "fit" in their orifices.  Diagnosis is often delayed.  Anxiety abounds before and during evaluation and management.     Most common objects : 1,2 Food Coins Toys Insects Balls, marbles Balloons Magnets Crayon Hair accessories, bows Beads Pebbles Erasers Pen/marker caps Button batteries Plastic bags, packaging Non-pharmacologic technique...

When you give only after you're asked, you've waited too long. – John Mason First, learn to bag Place a towel roll under the scapulae to align oral, pharyngeal, and tracheal axes: Karsli C. Can J Anesth. 2015. Use airway adjuncts such as the oropharyngeal airway or a nasal trumpet. Use the two-hand ventilation technique whenever possible:   (See Adventures in RSI for more)     Supraglottic Airways...

When should you commit to getting urine? When can you wait? When should you forgo testing altogether? When do I get urine? Symptoms – either typical dysuria, urgency, frequency in a verbal child, or non-descript abdominal pain or vomiting in a well appearing child. Fever – but first look for an obvious alternative source, especially viral signs or symptoms. No obvious source? Risk stratify before...

N.B.: This month's show notes are a departure from the usual summary.  Below is a reprint (with permission) of a soon-to-be released chapter, Horeczko T. "Acute Pain in Children". In Management of Pain and Procedural Sedation in Acute Care . Strayer R, Motov S, Nelson L (eds). 2017.   Rather than the customary blog post summary, the full chapter (with links) is provided as a virtual reference. INT...

"By the pricking of my thumbs, Something wheezing this way comes." -- Witches in Macbeth , with apologies to William Shakespeare   "Bronchiolitis is like a pneumonia you can't treat. We support, while the patient heals." -- Coach, still apologetic to the Bard     The Who The U.S. definition is for children less than two years of age , while the European committee includes infants less than one yea...

Johnny has fallen on an outstretched hand, and comes to you with a swollen, painful elbow.   Position of comfort, analgesia, xrays, and now what?   What am I seeing -- or not seeing -- here?     First a refresher on radiographic anatomy of the elbow --   Images courtesy of Radioglypics (Open Access Radiology Education) . Used with permission. Now that we have our adult anatomy reviewed, let's go t...

Blood in the vomit. Blood in the stool. Blood in the diaper. How far do I go in my investigation? What do I really have to worry about?   The differential diagnosis of GI bleeding in children is broad . ( Here is the complete differential diagnosis ) In the ED, we can simplify by categorizing by age and appearance .     Neonates GI bleeding in the neonate (less than one month of age) is serious un...

Seemingly vague, but potentially dangerous... common, but possibly with consequences... ...or maybe just plain frustrating. Let's talk risk stratification, diagnosis, and management. Primary or Secondary? We can make headache as easy or as complicated as we like, but let's break it down to what we need to know now, and what the parents need to know when they go home. Primary headaches: headaches w...

Have you ever been in any of these situations? ⇒   You have a stable child who just needs fluids, but no laboratory tests ⇒   You've tried PO hydration, to no avail, despite anti-emetics ⇒   You're poking the stable, but dehydrated child repeatedly without success What now? Hypodermoclysis , otherwise known as subcutaneous rehydration . [Insert Player] Clysis comes from the same Greek word that "a...

" She won't walk ", or " He just looks like he's limping ". So many things can be going on -- how do we tackle this chief complaint? You're dreading a big work-up.  You almost want to tell the kid – please, STOP LIMPING... STOP LIMPING! S – Septic Arthritis  The most urgent part of our differential diagnosis. The hip is the most common joint affected, followed by the knee.  Lab work can be helpful...

Do we recognize shock early enough? How do we prioritize our interventions? How can we tell whether we’re making our patient better or worse ?   World wide, shock is a leading cause of morbidity and mortality in children, mostly for failure to recognize or to treat adequately. So, what is shock? Simply put, shock is the inadequate delivery of oxygen to your tissues.  That’s it.  Our main focus is...

How do you approach the child who may be altered?   Altered mental status in children can be subtle .  Look for age-specific behaviors that range from irritability to anger to sleepiness to decreased interaction . In the altered child, anchoring bias is your biggest enemy.  Keep your mind open to the possibilities, and be ready to change it, when new information becomes available. For altered adul...

It's a busy shift.  Today no one seems to have a chief complaint. Someone sends a troponin on a child.  Good, bad, or ugly, how are you going to interpret the result? And while we’re at it – what labs do I need to be careful with in children – sometimes the normal ranges of common labs can have our heads spinning! Read on to go from bread-and-butter pediatric blood work to answer the question – wh...

A 5-year-old boy was playing with his older brother in front of their home when he was struck by a car. He sustained a femur fracture, splenic laceration, and blunt head trauma – the so-called Waddell’s triad. On arrival, he was in compensated shock, with tachycardia. He decompensates and needs blood. How do we manage his hemodynamics and when do we perform massive transfusion? Pediatric Massive T...

Traumatized children need your full attention. Protocols work well for adults, but trauma in children requires that we exercise our clinical muscles just a bit more.   Two main reasons:  Children have specific injury patterns  Their physiologic response to trauma is unique.   Crash course in pediatric anatomy and physiology in trauma When you think of trauma in children, think of Charlie Brown . L...

In the young child, vomiting is the great imitator: Gastrointestinal, Neurologic, Metabolic, Respiratory, Renal, Infectious, Endocrine, Toxin-related, even Behavioral. To help us organize, below is a review of can't-miss diagnoses by age. The Neonate: Malrotation with Volvulus In children with malrotation, 50% present within the first month of life , with the majority occurring in the first week a...

Victims of electrical injuries present either in extremis or as the seeming well patient with insidious, developing disease. A targeted history usually gets you the information you need.     Four main things to find out: 1. Household or Industrial electricity? Household electricity uses alternating current , or AC .  Voltages across the world range anywhere from 100 to 240 V.  Here in North Americ...