Tweets of Pediatric EM Pearls from ACEP SA

 

These are tweets from #ACEP12 SA by @DocWagz and @Dr_CommonSense lecture by Dr. Roosevelt on Pediatric EM Tricks. 

Mythbuster: Pediatric coin ingestion vs aspiration?

Is this coin in the esophagus or the trachea?

The classic teaching for the Boards exam is:

• Esophageal coins appear in the coronal plane, as shown above.
• Tracheal coins appear in the sagittal plane because of the cartilaginous tracheal rings.

Mythbuster: 
A case series of 8 pediatric patients were documented with coins positioned in a sagittal plane were actually in the esophagus! This data was collected over 15 years.

• Age range 3-17 years old
• Location of coin: 7/8 at level of aortic notch and 1/8 at distal esophagus 

The classic teaching likely still holds true most of the time (sagittal coin = tracheal foreign body), but don't rush to immediate judgment. Take a look at the lateral view, and see where the coin is located with respect to the trachea and airway. It may be more posterior, in which case, it's in the esophagus.

Thanks to Dr. Matt Anderson (Resident at Univ. of Wisconsin EM program) for the tip!


Reference

Schlesinger AE, Crowe JE. Sagittal orientation of ingested coins in the esophagus in children. AJR Am J Roentgenol. 2011 Mar;196(3):670-2. Pubmed .

Trick of the Trade: A flexible pediatric ear curette

Image from univatty.blogspot.com

Having you had trouble seeing a pediatric patient's tympanic membrane because of impacted cerumen? Scared from that last time you used a rigid curette and caused bleeding in the ear canal? The parents   are worried that you hit the brain...

Trick of the Trade:
Make a customized, softer, flexible curette using a polyester-tipped applicator

The thin polyester-tipped applicators have a malleable and relatively soft handle. Fold the applicator in half and twist the apposing edges into a single curette instrument. You can shape the curette to adjust the angle to your patient's ear canal anatomy and adherent cerumen chunks.

Thanks to Dr. Aaron Kornblith (chief resident at UCSF-SFGH EM program).

KidsCareEverywhere-Vietnam study findings: SAEM 2012 meeting

I recently had the pleasure of presenting our KidsCareEverywhere-Vietnam team's study findings at the national SAEM meeting in Chicago.

Bottom line: 
Despite knowing English as a second language, Vietnamese physicians were able to easily navigate an English-based, clinical decision support software (PEMSoft) after only a brief 80-minute training session, conducted by non-physicians. Their post-test exam scores improved by 84%!

SAEM meeting: May 9-12, 2012 in Chicago

What are you doing this week? Are you at the annual SAEM meeting in Chicago? Stop by and say hi. There is an impressive list of abstract presentations for the meeting. I'll be giving an oral presentation on research data from KidCareEverywhere:

"An English-based pediatric emergency medicine software improves physician test performance: A multicenter study in Vietnam"

All I get is 5 minutes. By the time I read the title, I'll only have 4 minutes left!

Paucis Verbis: Kawasaki Disease

Kawasaki Disease can be easy to diagnose when you have the pediatric patient, who presents with all 5 of the classic clinical findings. What happens when you have the prerequisite fever for ≥5 days, but only 2-3 clinical criteria?

• What ARE the 5 classic findings? 
• When do you do waitful watching?
• When do you perform an echo? 
• When do you treat empirically? 

Check out the nice flowchart below which addresses these questions. They summarize the most recent (2004) American Heart Association's consensus group's recommendations.

You can download this PV card: [MS Word] [PDF]

See other Paucis Verbis cards.

Reference

Newburger JW, Takahashi M, Gerber MA, Gewitz MH, Tani LY, Burns JC, Shulman ST, Bolger AF, Ferrieri P, Baltimore RS, Wilson WR, Baddour LM, Levison ME, Pallasch TJ, Falace DA, Taubert KA; Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease; Council on Cardiovascular Disease in the Young; American Heart Association; American Academy of Pediatrics. Diagnosis, treatment, and long-term management of Kawasaki disease: a statement for health professionals from the Committee on Rheumatic Fever, Endocarditis and Kawasaki Disease, Council on Cardiovascular Disease in the Young, American Heart Association. Circulation. 2004 Oct 26;110(17):2747-71. .

Free iPad contest: Be a PEMSoft app tester

Hot off the press from the folks over at PEMSoft:

Be the first to see the beta version of the new PEMSoft App on a FREE iPad 2. You can help bring PEMSoft App to life by using the beta app in your clinical unit, whether that be the pediatric emergency department, pediatric inpatient service, or pediatric ICU.


All you need to do is give feedback on the beta version over three separate 4-week blocks. Between the 4-week blocks, the team will be upgrading and improving the app based on multiple feedback sources including you! Afterwards, you get to keep the iPad 2.

Conditions:

• There will only be 1 winner chosen.
• The App is to be used on the iPad 2 in a pediatric unit or pediatric emergency department by the physician team on a daily basis.
• We would like feedback on the App relating to how it is working, any errors found, and suggestions for improvement. 
• You will provide weekly feedback over three discrete 4-week block periods.
• After the feedback period, you keep the iPad 2. 

To enter, email a short paragraph to support@pemsoft.com on how and why you think your pediatric team can use the new PEMSoft App.

Application deadline: May 11, 2012


Disclosure: I am the Procedures section editor for PEMSoft and part of the nonprofit organization KidsCareEverywhere, which distributes free copies of PEMSoft to underserved countries.

Paucis Verbis: Pediatric fever without a source (3 mo-3 yr)

In part 3 of this "Pediatric Fever Without a Source" Paucis Verbis cards, we now cover febrile infants 3 months to 3 years old (PV cards for birth-28 days and 29 days-3 months old).

Notes:

• The algorithm below is a guideline for NON-toxic patients. More ill-appearing children require a more broad workup.
• For the under-immunized (<2 PCV immunizations) and temperature ≥39.5C, blood cultures may be falling out of favor in the near future, because the incidence of blood culture contaminants is close to exceeding the true incidence of occult bacteremia.

You can download this PV card: [MS Word] [PDF]

See other Paucis Verbis cards.

Thanks to Dr. Hemal Kanzaria (UCSF-SFGH resident) for helping design this PV card and Dr. Christine Cho, Dr. Andi Marmor, and Dr. Ellen Laves (UCSF Pediatrics) for the content.

Paucis Verbis: Fever without a source (29 days-3 months old)

In part 2 of this "Pediatric Fever Without a Source" Paucis Verbis cards, we now cover febrile infants aged 29 days to 3 months (PV card for birth-28 days). Note that there is no single correct answer in how to manage these patients. There can be a wide variation in practices, partly because of the slightly different criteria used by the 3 studies. The overarching principle is that "high risk" infants get admitted with IV ceftriaxone and "low risk" infants get discharged with close follow-up +/- a ceftriaxone IV or IM dose. The line between these two risk categories is the grey area.

Where I practice, we tend to follow a modified version of the Rochester criteria, where a lumbar puncture and antibiotics aren't always required for this age group (unlike the Boston criteria).

You can download this PV card: [MS Word] [PDF]

See other Paucis Verbis cards.

Keep a lookout for future PV cards which will address fevers without a source in pediatric patients aged 3 months-3 years old.

Thanks to Dr. Hemal Kanzaria (UCSF-SFGH resident) for helping design this PV card and Dr. Christine Cho, Dr. Andi Marmor, and Dr. Ellen Laves (UCSF Pediatrics) for the content.

Paucis Verbis: Pediatric fever without a source (Birth-28 days)

Pediatric patients commonly are brought to the Emergency Department for a fever without a source. Management of these patients depends on the patient's age. Today's PV card focuses on the youngest age group: Birth-to-28 days.

QUESTION to everyone:

• Do you correct your age calculation for prematurity? Premature neonates are more at risk for SBI, but I've seen varying practices.

You can download this PV card: [MS Word] [PDF]

See other Paucis Verbis cards.

Keep a lookout for future PV cards which will address fevers without a source in pediatric patients aged 29 days-3 months and 3 months-3 years old.

Thanks to Dr. Hemal Kanzaria (UCSF-SFGH resident) for helping design this PV card and Dr. Christine Cho, Dr. Andi Marmor, and Dr. Ellen Laves (UCSF Pediatrics) for the content.

Students/residents: Free 1-yr subscription to PEMSoft

A January 2012 special! 

It is still the season of giving… for medical students and residents. 

The Editors-in-Chief of PEMSoft (Pediatric Emergency Medicine Software) want to share a one-year free subscription to a dynamic online pediatric EM reference. PEMSoft brings the medical library to the bedside! It is a point-of-care clinical support tool and knowledge system that is indispensable if you care for sick neonates or young adults. PEMSoft is also a superb educational resource--with over 3000 images and videos, as well as multiple interactive modules to refine diagnosis and treatment, and a sophisticated search engine to find topics instantly and to generate differential diagnosis.

PEMSoft has had a total makeover in 2012, with more than 8 special modules added to the updated vast, core knowledge base that now includes over 2000 topics. This new interface is especially suited for use on tablets and mobile devices at the bedside and on rounds. Previous reviews of the software have declared it "a new publication that completely resets the standards in its field" (Ped Emerg Care, 23(8); 2007). Test it out the new version for yourself! See our informational website at www.pemsoft.com for more details and testimonials from your colleagues.

I recently delivered donated versions of PEMSoft and trained tons of grateful physicians in Vietnam, on behalf of KidsCareEverywhere. A personal subscription of the online software currently currently costs $95/yr. In full disclosure, I am one of their section editors. I manage the multimedia Procedures section. If you listen closely, you'll hear my voiceover in several of the videos.

• Visit our informational website: www.pemsoft.com
• Enter the software itself: www.pemsoft.net
• "Like" us on Facebook: http://alturl.com/kwpsz

How do you get this amazing 1-year free subscription? Fill out the form below, and I'll personally email you your username and password.

The deal expires Jan 31, 2012.

Advice for the new EM interns, part II

As a followup to a previous post on "The 10 Commandments in Emergency Medicine", we would like to pay tribute to our pediatric friends. More than a decade after it was initially published, Timothy Givens (also from Vanderbilt but the pediatric side) published "The 10 commandments of pediatric Emergency Medicine". Although the original commandments still hold true, the pediatric commandments augment them nicely and are geared towards our littler patients.

1. Children are not small adults.

2. Ill and injured children regress.

3. The "patient" might be the one holding the child.

4. Kids are the real deal.

5. Laboratory tests and x-rays seldom beat a good history and physical examination.

6. Many hands make light work.

7. Check and double-check. Then, check again.

8. Children feel pain just like you do - treat it.

9. Close the loop.

10. Above all, you are the child's advocate.

Welcome to the new interns!

Reference

Givens T. The ten commandments of pediatric Emergency Medicine. J Emerg Med. 2004;27(2):193-4. DOI: 10.1016/j.jemermed.2004.05.002
.

Trick of the Trade: Balloon animals in the ED

Back in July 2010, I wrote about using the Candleflame app to encourage pediatric patients to take deep breaths for a pulmonary exam. This app has also been useful in helping me roughly gauge the patient's peak flow.

Trick of the trade:

Balloonimals app

What kid doesn't love balloon animals? 

You can download the Balloonimals "Lite" app on your iPhone for free. Have the child blow forcefully at the mouthpiece of your iPhone. This will inflate a balloon. Shaking your iPhone will magically convert the balloon into a cute T-Rex dinosaur. Touching the screen will animate the 3D dinosaur. Touching the air pump icon will pop the balloon.

Balloonimals Lite app [iTunes app store]



For an extra $1.99, you can download the full version, which includes different balloon animals.



Thanks to Dr. Susan Brim (UCSF-SFGH EM resident) for the tip! Disclosure: I do not have any affiliations with the company.

Hot off the press: Clinical practice guideline for ketamine in the ED

A 3 year old girl is brought into the ED with an abscess to her groin. Upon examination it is fluctuant and needs incision and drainage. Next door is a 5 year old boy, who fell off his bed and has an angulated radius fracture that needs reduction.

Hhhmmmm...how to manage these patients? Local anesthesia? Hematoma block? Nothing (aka brutacaine)? What about ketamine, that seems popular these days. IV? IM? With or without atropine? So many decisions!

Luckily you were surfing the internet one night and came across the 2011 clinical practice guideline on ketamine in the ED, which was just published.

This practice guideline was updated from a previous 2004 version because of new research that proved/disproved the way ketamine was being utilized. It was compiled by four physicians that are experts in the field of ketamine sedation, two of which wrote the 2004 practice guideline. Updated research was found by performing a MEDLINE search from January 2003 to November 2010 using the search term "ketamine".

Highlights:

1. Adults have been included in the 2011 guidelines.

2. Adjunctive medications

• Prophylactic ondansetron can help reduce vomiting. The number needed to benefit = 9.
• No need to co-administer atropine or glycopyrrolate for oral secretions.
• Prophylactic midazolam 0.3 mg/kg may prevent recovery reactions in adults (but not children). The number needed benefit = 6.

3. Contraindications

• Age < 3 months because of risk of airway complications
• Known or suspected schizophrenia (even if currently stable)
• Head trauma has been removed as a contraindication.

4. Route of administration

• IV administration appears to be preferred over IM, because of faster recover and fewer episodes of emesis.
• IV route: Peak concentration and onset = 1 min, duration of dissociation = 5-10 min, time from dose-to-discharge = 50-110 min
• IM route: Peak concentration and onset = 5 min, duration of dissociation = 20-30 min, time from dose-to-discharge = 60-140 min 

5. Complications

• Laryngospasm has been reported to be around 0.3%. What do you do when this happens? You'll just have to read this previous post to find out.

Reference

Green SM, Roback MG, Kennedy RM, Krauss B. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update. Annals of emergency medicine. 2011 - in press. PMID: 21256625
.

Tricks of the Trade: Nursemaid elbow reduction

We've all seen it before while working in the ED. A parent brings in their child because they pulled on their arm, and now the child is not using it. Parents are thoroughly convinced that the child's arm is either broken or dislocated. We all recognize this as radial head subluxation or "nursemaid's elbow" and immediately attempt to reduce it. The provider takes the injured arm, supinates at the wrist and flexes at the elbow. Does the child scream? Does the parent scream and threaten to sue? What if nothing happens?


Trick of the Trade: Hyperpronation technique
A 2009 paper by Bek et al. describes a method of pronation instead of supination. The proposed maneuver involves one hand holding the elbow at 90 degrees of flexion and the other hand holding the wrist. The wrist is then hyperpronated to complete the reduction.

Sixty-six patients were randomized to either a traditional reduction or the hyperpronation maneuver. If the initial attempt failed, a second attempt was performed. If the second attempt failed, then the alternate method was performed. Bottom line...hyperpronation was 94% successful on the first attempt compared to supination-flexion at 69%. Three patients failed supination-flexion (first and second attempt) but were successfully reduced with hyperpronation on the first attempt. Hyperpronation was also subjectively rated as significantly easier then supination-flexion by the practitioner.

I've been using hyperpronation for the past several years and love it. The maneuver appears less traumatic on the child (and parent).

Has anyone else tried it? I'd love to hear your experiences!

Reference
Bek D et al. Pronation versus supination maneuvers for the reduction of ‘pulled elbow’: a randomized clinical trial European Journal of Emergency Medicine. 2009, 16(3), 135-8. DOI: 10.1097/MEJ.0b013e32831d796a

Trick of the Trade: Laryngospasm notch maneuver

What is the incidence of laryngospasm in pediatric patients receiving ketamine for procedural sedation in the ED?

Answer = 0.3%

A child with laryngospasm can be a scary thing to manage. There's no way to predict whether a child is going to get it.

You can try the usual maneuvers including a jaw-thrust, positive pressure ventilation to try to open the vocal cords, and suctioning. If these don't work, you might consider giving the patient a paralytic, such as succinylcholine, and performing an endotracheal intubation for worsening hypoxia. Before that, what non-invasive maneuver can you try first?

Trick of the Trade: Laryngospasm notch maneuver
This maneuver, mentioned in the anesthesia literature, is more based on a single physician's longitudinal experiences (Dr. Philip Larsen, Professor of Clinical Anesthesiology at UCLA). Anecdotally, many pediatricians and anesthetists use it. I haven't found any published studies on this maneuver though. Interestingly though, I've found it mentioned in 2 EM blogs by Life In The Fast Lane and Dr. Bearemy from earlier this year. Better late than never for me, I suppose.

Technique:
Firmly push the soft tissue just behind the earlobes of the patient's ears. Be sure not to go too inferiorly along the ramus of the mandible. You want to push at a point as superior as you can go in this notch. Push both sides firmly inward towards the skull base. Simultaneously, push anteriorly similar to a jaw-thrust maneuver. This should break the laryngospasm within 1-2 breaths.

It's unclear about the mechanism behind why this works. Here are some theories:

• You are just performing a jaw-thrust maneuver. 
• You are providing a deep painful stimuli, which causes the vocal cords to relax. 
• You are stimulating deep cranial nerves which happen to also stimulate the vagus nerve. 

Anyone have success with this maneuver in the pediatric patient? It would be a great case report publication. Nothing in the literature at this point. 

Read the original online commentary by Dr. Philip Larson in the Anesthesiology journal.

KidsCareEverywhere: 2010 Vietnam Video Documentary

KidsCareEverywhere is a non-profit group that I've been a part of for the past 3 years. I'm actually one of the Board Members and the Director of Research (since there's a large educational research component in our outreach efforts). The group delivers a clinical decision software (PEMSoft) to pediatricians in developing countries. This software essentially replaces their medical libraries and brings references and tools to the bedside.

I just returned from a recent trip to Vietnam. Got some amazing video footage and photos. It was tough to get things down to a 7 minute video.

It really is amazing what you can do with a little technology and a lot of free time:

• Three of us simultaneously edited the script on Google Docs from our respective homes.
• Adobe Flash is a software worth learning. It let me add in those nifty animations that can get converted into .mov format. These are then importable into iMovie. It can suck up all your time trying to get the animations just right, but a great visual goes a long way.
• I found a great Creative Commons website with royalty-free music by Kevin McLeod. If you need some great background soundtracks, check it out here.

Paucis Verbis card: Algorithm for suspected pertussis in pediatrics

To treat for pertussis or not? 

In the setting of the current pertussis epidemic in California, each kid with a cough sparks constant debate about whether to treat with azithromycin or not. Finally, thanks to my friends Dr. Andi Marmor and Dr. Shon Agarwal Jain (UCSF Pediatrics faculty), there's a great algorithm to help you answer the question. I have found this algorithm extremely helpful.

You basically start by risk-stratifying by age and pertussis immunization status. For instance, if the patient is <3 months of age (or >6 months of age AND unimmunized), then follow the algorithm listed as "High Risk for Pertussis".

(click to enlarge)

Feel free to download this card and print on a 4'' x 6'' index card.

[MS Word] [PDF]

See other Paucis Verbis cards.

Tricks of the trade: Intranasal fentanyl for pediatric patients

Pediatric patients often receive inadequate pain control in the setting of orthopedic injuries. Because the child experiences fear, anxiety, and pain with needles, practitioners often shy away from ordering IV or IM pain medications. Oral agents, while easier to administer, usually provide inadequate pain control.

Trick of the Trade:

Intranasal (IN) fentanyl

Thanks to my friend Dr. Ron Dieckmann (Editor-in-Chief for PEMSoft, Chairman of Board for KidsCareEverywhere, and Pediatric Director for Valley Emergency Physicians) for his tip about intranasal fentanyl:

It is imperative that the drug be administered in a nebulized form using an atomizer device -- one half the volume in each nostril. Attach a 1 cc syringe to the end of the atomizer to administer fentanyl intranasally.

It is rapidly absorbed and provides excellent analgesia within minutes. It works just as well as IV morphine (1). If you just drop the liquid in the nose without using the atomizer, the child will swallow some of the drug, and onset and effect will be blunted significantly and titration is not possible.

The starting dose of 1.5 microgram/kg can be repeated in a dose of 0.5-1.5 microgram/kg IN in 5 minutes.  Be sure to use extreme caution in younger patients who are more susceptible to the respiratory depressant effects of all opiates; it has not been tested in children < 3 years of age at all, so I would not use in this age group. Put patients on a pulse oximeter. In the event that a child receives the drug and starts to desaturate, bag the patient, then just give naloxone 0.1 mg/kg/dose to a maximum of 2 mg intramuscularly, and the respiratory effects will be rapidly reversed.

Do you use intranasal fentanyl at your practice?

Reference
1. Borland M, Jacobs I, King B, O'Brien D. A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med. 2007 Mar;49(3):335-40.

Paucis Verbis card: Pediatric weight-based reference (5-34 kg)

The foundation in any pediatric resuscitation is the length-based estimation of the patient's lean body weight. Once determined, equipments and medications are sized and dosed, respectively, according to that weight. You can use electronic resources such as PEMSoft (Pediatric Emergency Medicine Software) or the more traditional paper-based Broselow tape.

If you have neither of these at your easy disposal, I thought I would create a multi-card reference which works best in electronic pdf form on your mobile device. (Remember, I'm also sharing my Paucis Verbis cards using Dropbox.) Even if you DO have other available references, it's still nice to have some redundant back-up sources just in case.

This data was collected by merging data from the Broselow tape and PEMSoft.

• I created 30 individual cards for patients weighing between 5 kg and 34 kg. 
• I didn't include whether endotracheal tubes should be cuffed or uncuffed. This is controversial currently. The traditional teaching is that patients younger than 8 years old should receive UNcuffed tubes.
• D10W glucose should be given in patients younger than 1 year old. D25W glucose should be given for patients 1-2 years old. D50W glucose can be given to patients 2 years and older.
• Please use these cards with caution. I've proof-read these cards multiple times, but there still may be some typos. Please let me know if you see any discrepancies.

Example card for 10 kg child:

Feel free to download this card and print on a 4'' x 6'' index card.

[MS Word] [PDF]

See other Paucis Verbis cards.

Disclosure- I am one of the editors for PEMSoft. I just returned from a KidsCareEverywhere's trip to Vietnam, where we taught over 200 pediatricians how to use the software to improve their resuscitation skills.