Tag Archives: peds

Epiglottitis (quick hits)

24 Apr

General:

-Also can be referred to as supraglottitis

Haemophilus influenza type b (cause approximately 25% of cases even now after vaccination), Staphylococcus and Streptococcus species are the most common causes

 

Features:

-Classic 3 D’s= Drooling, dysphagia, and distress

-Commonly describe worsening dysphagia, dysnpea,

-Fever, tachycardia, and cervical lymphadenopathy also presently common

-Insiratory stridor

-Patients often are sitting in the sniffing position to provide easier breathing

 

Diagnosis:

Xrays can be obtained which show “thumb sign”if you are really concerned about epiglottis and the patient is unstable, do any necessary imaging at the bedside

-Transnasal fiberoptic laryngoscopy is the imaging test of choice

-CT is not needed and should be avoided in any patient who develops worsening symptoms with laying down

 

Treatment:

-Supplemental humidified oxygen

-ENT consultation

-IV antibiotics (Ceftriaxone is first line drug)

-IV steroids

-ENT consultation

 

NOTE:  If intubation is needed, try performing awake fiberoptic intubation in the OR with tracheostomy equipment available if needed

 

Submitted by Joey Grover. 

 

References: Image: http://www.nejm.org/na101/home/literatum/publisher/mms/journals/content/nejm/2011/nejm_2011.365.issue-5/nejmicm1009990/production/images/large/nejmicm1009990_f1.jpegTintinalli’s Emergency Medicine 7th Edition

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sweet smells, less pain

21 Apr

 Neat tip in April’s ACEP Now mag by Dr. Mell:

HIGHLIGHTS:

sweet-smelling  (e.g. cherry/blueberry/watermelon) lip balm coated the inside of a pediatric non-rebreather mask

letting patients pick the flavor gives them some small measure of control

some studies suggest sweet/pleasant odors may improve pain tolerance

works with oral solutions, seems like odors might work, too.

add it to the toolbox.

References: ACEP Now article; less pain with odors; less pain with sweets; picture.

 

 

Can you use absorbable sutures for pediatric lacerations?

10 Dec

pedslac1

Since we all know much children love needles and stitches, many pediatricians and EM physicians 
have been looking at ways to make lace
ration repair less painful.

Before we talk about the suture types, many physicians are using LET (lidocaine/epinephrine/tetracaine) gel (as we use prior to IV’s) for anesthesia to avoid an injection.  I have found this quite useful.  It takes ~ 20 minutes to work- you also do generally see blanching at the site.  It lasts up to 30-45 minutes after being wiped off for suturing.

 

There are numerous studies in the past 10 years suggesting absorbable sutures are at least equivalent to non-absorbable sutures for facial lacerations in children.  One of the more convincing studies I found is a study done by Karounis in 2004:

 

* Objective: Compare the long-term cosmetic outcome between absorbable and non-absorbable sutures in pediatric lacerations (not limited to the face).  They also looked at infection rate and dehiscence.

 

* Methods: RCT with 95 patients (1-18 years old) assigned to repair with plain gut (50 pts) or nylon (45 pts).   Wound evaluation scores (WES) assessed at 5-10 days by a nurse and then at 4-5 months by a plastic surgeon, who also assigned a visual analog scale (VAS)

 

pedslac2*ResultsSlight cosmetic improvement that is was not statistically significant in pts with plain gut (absorbable) repair.  This was seen in both the repeat WES and VAS.  No significant difference between infection rate or dehiscence rate (slightly lower in absorbable group but not statistically significant).

 

*Conclusion: This supports absorbable sutures being used for pediatric lacerations with good cosmetic outcomes without an increase in the rate of infection or dehiscence (both were slightly lower in the plain gut group).

 

Bottom Line: Using absorbable sutures in kids seems like a reasonable option.  On my pediatric EM rotation, we routinely used absorbable sutures for lacerations in kids- on the face and extremities (typically 5-0 to 6-0 fast gut on the face and 4-0 to 5-0 chromic gut on the body).

 

Submitted by H. Groth.

 

SourcesEvans, R et al. “Absorbable sutures in paediatric lacerations”. Emerg Med J, 2006 January; 23(1): 64-65.;  Luck, RP et al. “Cosmetic Outcomes of Absorbable Versus Nonabsorbable Sutures in Pediatric Facial Lacerations” Pediatric Emergency Care, 2008 March; 24(3); 137-142.; Karounis, H. et al. “A Randomized, Controlled Trial Comparing Long-Term Cosmetic Outcomes of Traumatic Pediatric Lacerations Repaired with Absorbable Plain Gut versus Nonabsorbable Nylon Suture” Academic Emergency Medicine, 2004 July; 11(7); 730-735.

hyperpronation for Nursemaid’s elbow

26 Nov

nice quick overview in a recent EP Monthly mag. Some quick pearls below:

 

TECHNIQUE:

  • one hand holding elbow at 90 degrees
  • other hand holds wrist
  • hyperpronate the wrist
  • voila!

 

DATA:

couple small studies comparing hyperpronation technique vs. supination-flexion reduction

  • hyperpronation 94 & 96% successful in 2 studies
  • supination-flexion 68 & 69% successful in 2 studies

 

BOTTOM LINE:

hyperpronation seems like a reduction method worth trying, seems pretty successful

 

References: epmonthly article (+ pic from article)

 

pediatric pain management: quick reference

21 Oct

Nice article in this month’s ACEP News mag.  In particular, has some nice quick reference tables for topical options and some PO/IV analgesics:

Check out the tables below, click through for the whole article:

anes1 anes2

 

 

References: ACEP News article (+ tables)

Kawasaki Disease (30-second review)

20 Jun

Sensitivity of physical exam findings:

Fever x 5 days plus at least 4/5 of:

1. Conjunctival injection (bilateral)

2. MM changes (eg. Fissured lips, strawberry tongue)

3. Polymorphous rash

4. Extremity changes (edema, desquamation)

5. Cervical LAD

 Sensitivity 90%, specificity 54%

 

20-25% develop coronary aneurysms, typically clinically silent until sudden death

 

IVIG reduces aneurysms to only 2-4% cases

 

MIMICKERS – GAS pharyngitis (scarlet fever), measles

 

Med-school mnemonic: CRASH & BURN

  • Conjunctivitis
  • Rash
  • Adenopathy/Aneurysm
  • Strawberry tongue
  • Hand/foot induration/desquamation

&

  • BURN – fever x 5 days

 

 

Submitted by J. Andrick.

 

References: Kawasaki Syndrome, Burns, Glode review Lancet 2004; Kawasaki Disease II Yim et al. J Ped Child Health.; picture

Pediatric Foreign Body Aspiration

19 Jun

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Submitted by F. DiFranco.

 

References: Rovin JD & Rodgers BM. Pediatric Foreign Body Aspiration. Pediatrics in Review. 2000; 21(3): 86-89.; picture