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American College of Emergency Physicians (ACEP): Advanced Pediatric Emergency Medicine Assembly
Ultrasound expedites pediatric emergency evaluations
LAKE BUENA VISTA, FLA. – Ultrasound expedites clinical decision making and often dictates the next step to pursue when managing children in the emergency department.
"It makes sense to use ultrasound for pediatric patients, but there’s been a delay in picking up this idea. Only now is (the use of bedside ultrasonography) becoming more prevalent in pediatric emergency medicine, Dr. Stephanie J. Doniger said at a meeting sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics.
"Among the advantages is that we really never have to perform sedation, and the absolutely most important thing, we don’t need to use ionizing radiation," said Dr. Doniger, director of emergency ultrasound at Children’s Hospital and Research Center, Oakland, Calif.
Still, she said, there are no clear guidelines for ultrasonography’s use in pediatric emergencies. No one body oversees the quality in training or in outcomes. In 2009, ACEP updated its guidelines on bedside ultrasound in the emergency department. The group gave a nod to pediatric use, calling ultrasonography "an ideal diagnostic tool for children ... As in adult patients, emergency ultrasound in children can be life saving, time saving, [can] increase procedural efficiency, and [can] maximize patient safety."
The document says ultrasound is particularly useful in performing the FAST exam, and for bladder evaluations prior to instilling a catheter in infants. Dr. Doniger noted a number of other applications as well.
Ultrasonography is valuable for assessing dehydration by providing a look at the inferior vena cava. "We’re looking here for collapsibility during inspiration. Collapsibility of more than 50% correlates with dehydration."
Appendicitis is tough to image, radiographs are unreliable, and "CTs aren’t great, but we do them if we have to." But ultrasound provides a very good look into what lies beneath, and is one more way to reduce a child’s cumulative radiation dose.
A 2008 study found that a 5-minute bedside ultrasound had a sensitivity of 65% and a specificity of 90% for appendicitis. The positive predictive value was 84%, and the negative predictive value, 76%.
"That might not sound great, but it is a good result to rule in disease. If you have a high suspicion of appendicitis, then use it; if a low suspicion, then don’t."
When looking for an infected appendix, start at the point of maximal tenderness and move to the right while the child is in an oblique position. "It helps if you prop up the hip with some towels," Dr. Doniger said. "The bowel will move away and you’ll have a better view when you compress."
Look for a noncompressible tubular structure with a diameter greater than 6 mm.
The probe can also help find intussusception – a condition that x-rays identify 40%-90% of the time. The ultrasound image of intussusception is target- or doughnut-shaped – a figure formed when the bowel retracts back into itself. A study found that even beginning sonographers can identify this classic sign. Their exams had a sensitivity of 85%, a specificity of 97%, a positive predictive value of 85%, and a negative predictive value of 97%.
Even something that seems innocuous on the surface – like a splinter – will give up its secrets under the ultrasound probe. Foreign bodies may or may not show up on an x-ray, but they are obviously hypoechoic on ultrasound, she said.
Dr. Doniger presented the case of a 13-year-old who thought he got a splinter under his fingernail, but wasn’t sure. He came to the emergency department after his finger became stiff and a little painful. Ultrasound identified the culprit as splinter of wood that was more than 1 inch long.
Guiding the needle during an evaluation for painful hips for effusion is another great use for ultrasound, she said. A 2009 study determined that, compared with ultrasound alone; sonography-guided arthrocentesis for symptomatic hips had 90% sensitivity and 100% specificity, with a 100% positive predictive value and a 92% negative predictive value.
Ultrasound also provides valuable assistance in identifying the landmarks for successful needle placement when performing a spinal tap. A 2007 study equally randomized 46 children to finding the landmarks by palpation or with ultrasound. There were six failed attempts in the palpation group and one in the ultrasound group. Ultrasound was particularly helpful in obese children; four of seven palpation placements failed, compared with no failures in the ultrasound group.
None of the authors declared any financial relationships. The study was funded by the Lynn Sage Cancer Research Foundation, the Avon Foundation, and a private contribution.
LAKE BUENA VISTA, FLA. – Ultrasound expedites clinical decision making and often dictates the next step to pursue when managing children in the emergency department.
"It makes sense to use ultrasound for pediatric patients, but there’s been a delay in picking up this idea. Only now is (the use of bedside ultrasonography) becoming more prevalent in pediatric emergency medicine, Dr. Stephanie J. Doniger said at a meeting sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics.
"Among the advantages is that we really never have to perform sedation, and the absolutely most important thing, we don’t need to use ionizing radiation," said Dr. Doniger, director of emergency ultrasound at Children’s Hospital and Research Center, Oakland, Calif.
Still, she said, there are no clear guidelines for ultrasonography’s use in pediatric emergencies. No one body oversees the quality in training or in outcomes. In 2009, ACEP updated its guidelines on bedside ultrasound in the emergency department. The group gave a nod to pediatric use, calling ultrasonography "an ideal diagnostic tool for children ... As in adult patients, emergency ultrasound in children can be life saving, time saving, [can] increase procedural efficiency, and [can] maximize patient safety."
The document says ultrasound is particularly useful in performing the FAST exam, and for bladder evaluations prior to instilling a catheter in infants. Dr. Doniger noted a number of other applications as well.
Ultrasonography is valuable for assessing dehydration by providing a look at the inferior vena cava. "We’re looking here for collapsibility during inspiration. Collapsibility of more than 50% correlates with dehydration."
Appendicitis is tough to image, radiographs are unreliable, and "CTs aren’t great, but we do them if we have to." But ultrasound provides a very good look into what lies beneath, and is one more way to reduce a child’s cumulative radiation dose.
A 2008 study found that a 5-minute bedside ultrasound had a sensitivity of 65% and a specificity of 90% for appendicitis. The positive predictive value was 84%, and the negative predictive value, 76%.
"That might not sound great, but it is a good result to rule in disease. If you have a high suspicion of appendicitis, then use it; if a low suspicion, then don’t."
When looking for an infected appendix, start at the point of maximal tenderness and move to the right while the child is in an oblique position. "It helps if you prop up the hip with some towels," Dr. Doniger said. "The bowel will move away and you’ll have a better view when you compress."
Look for a noncompressible tubular structure with a diameter greater than 6 mm.
The probe can also help find intussusception – a condition that x-rays identify 40%-90% of the time. The ultrasound image of intussusception is target- or doughnut-shaped – a figure formed when the bowel retracts back into itself. A study found that even beginning sonographers can identify this classic sign. Their exams had a sensitivity of 85%, a specificity of 97%, a positive predictive value of 85%, and a negative predictive value of 97%.
Even something that seems innocuous on the surface – like a splinter – will give up its secrets under the ultrasound probe. Foreign bodies may or may not show up on an x-ray, but they are obviously hypoechoic on ultrasound, she said.
Dr. Doniger presented the case of a 13-year-old who thought he got a splinter under his fingernail, but wasn’t sure. He came to the emergency department after his finger became stiff and a little painful. Ultrasound identified the culprit as splinter of wood that was more than 1 inch long.
Guiding the needle during an evaluation for painful hips for effusion is another great use for ultrasound, she said. A 2009 study determined that, compared with ultrasound alone; sonography-guided arthrocentesis for symptomatic hips had 90% sensitivity and 100% specificity, with a 100% positive predictive value and a 92% negative predictive value.
Ultrasound also provides valuable assistance in identifying the landmarks for successful needle placement when performing a spinal tap. A 2007 study equally randomized 46 children to finding the landmarks by palpation or with ultrasound. There were six failed attempts in the palpation group and one in the ultrasound group. Ultrasound was particularly helpful in obese children; four of seven palpation placements failed, compared with no failures in the ultrasound group.
None of the authors declared any financial relationships. The study was funded by the Lynn Sage Cancer Research Foundation, the Avon Foundation, and a private contribution.
LAKE BUENA VISTA, FLA. – Ultrasound expedites clinical decision making and often dictates the next step to pursue when managing children in the emergency department.
"It makes sense to use ultrasound for pediatric patients, but there’s been a delay in picking up this idea. Only now is (the use of bedside ultrasonography) becoming more prevalent in pediatric emergency medicine, Dr. Stephanie J. Doniger said at a meeting sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics.
"Among the advantages is that we really never have to perform sedation, and the absolutely most important thing, we don’t need to use ionizing radiation," said Dr. Doniger, director of emergency ultrasound at Children’s Hospital and Research Center, Oakland, Calif.
Still, she said, there are no clear guidelines for ultrasonography’s use in pediatric emergencies. No one body oversees the quality in training or in outcomes. In 2009, ACEP updated its guidelines on bedside ultrasound in the emergency department. The group gave a nod to pediatric use, calling ultrasonography "an ideal diagnostic tool for children ... As in adult patients, emergency ultrasound in children can be life saving, time saving, [can] increase procedural efficiency, and [can] maximize patient safety."
The document says ultrasound is particularly useful in performing the FAST exam, and for bladder evaluations prior to instilling a catheter in infants. Dr. Doniger noted a number of other applications as well.
Ultrasonography is valuable for assessing dehydration by providing a look at the inferior vena cava. "We’re looking here for collapsibility during inspiration. Collapsibility of more than 50% correlates with dehydration."
Appendicitis is tough to image, radiographs are unreliable, and "CTs aren’t great, but we do them if we have to." But ultrasound provides a very good look into what lies beneath, and is one more way to reduce a child’s cumulative radiation dose.
A 2008 study found that a 5-minute bedside ultrasound had a sensitivity of 65% and a specificity of 90% for appendicitis. The positive predictive value was 84%, and the negative predictive value, 76%.
"That might not sound great, but it is a good result to rule in disease. If you have a high suspicion of appendicitis, then use it; if a low suspicion, then don’t."
When looking for an infected appendix, start at the point of maximal tenderness and move to the right while the child is in an oblique position. "It helps if you prop up the hip with some towels," Dr. Doniger said. "The bowel will move away and you’ll have a better view when you compress."
Look for a noncompressible tubular structure with a diameter greater than 6 mm.
The probe can also help find intussusception – a condition that x-rays identify 40%-90% of the time. The ultrasound image of intussusception is target- or doughnut-shaped – a figure formed when the bowel retracts back into itself. A study found that even beginning sonographers can identify this classic sign. Their exams had a sensitivity of 85%, a specificity of 97%, a positive predictive value of 85%, and a negative predictive value of 97%.
Even something that seems innocuous on the surface – like a splinter – will give up its secrets under the ultrasound probe. Foreign bodies may or may not show up on an x-ray, but they are obviously hypoechoic on ultrasound, she said.
Dr. Doniger presented the case of a 13-year-old who thought he got a splinter under his fingernail, but wasn’t sure. He came to the emergency department after his finger became stiff and a little painful. Ultrasound identified the culprit as splinter of wood that was more than 1 inch long.
Guiding the needle during an evaluation for painful hips for effusion is another great use for ultrasound, she said. A 2009 study determined that, compared with ultrasound alone; sonography-guided arthrocentesis for symptomatic hips had 90% sensitivity and 100% specificity, with a 100% positive predictive value and a 92% negative predictive value.
Ultrasound also provides valuable assistance in identifying the landmarks for successful needle placement when performing a spinal tap. A 2007 study equally randomized 46 children to finding the landmarks by palpation or with ultrasound. There were six failed attempts in the palpation group and one in the ultrasound group. Ultrasound was particularly helpful in obese children; four of seven palpation placements failed, compared with no failures in the ultrasound group.
None of the authors declared any financial relationships. The study was funded by the Lynn Sage Cancer Research Foundation, the Avon Foundation, and a private contribution.
EXPERT ANALYSIS AT THE ADVANCED PEDIATRIC EMERGENCY MEDICINE ASSEMBLY
Warm, dry, and mad - a guide to newborn resuscitation
LAKE BUENA VISTA, FLA. – The best way to take advantage of a struggling newborn’s "Golden Minute" won’t be found in any schmaltzy pregnancy book.
"Dry ’em off and piss ’em off," Dr. Maureen McCollough said at a meeting sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics.
Delivery rooms have the ability to quickly mobilize the high-tech equipment that can mean the difference between life and death for these neonates. But not every baby is considerate enough to arrive under ideal circumstances, said Dr. McCullough, director of pediatric emergency medicine at the University of Southern California Medical Center, Los Angeles.
"Dad might have already delivered this baby in the car, or Mom comes in complaining of stomach pains and there’s a baby crowning right there in the emergency department. You need to be ready."
Dr. McCullough outlined the stepwise resuscitation algorithm endorsed by the American Academy of Pediatrics in its 2010 guidelines.
The algorithm starts with the basics. If the infant looks full term, is crying or breathing, and has good muscle tone, she probably won’t need much in the way of interventions. Dry and swaddle her and get her warm; Mom’s abdomen is the perfect place for this. If the baby is really small – less than 1,500 grams – turn to plastic wrap instead of a blanket. The impermeable barrier decreases heat loss through evaporation and holds more of the baby’s body heat in. If possible, raise the room temperature to around 79 , she advised.
"Hypothermia is associated with increased mortality," Dr McCullough said. In trying to warm herself, the hypothermic newborn increases her metabolic rate, leading to increased oxygen consumption.
Stimulation comes next. "Slapping or flicking the soles of the feet, rubbing the back, and drying and suctioning the baby is often enough to get things going."
If the baby looks preterm, things can get dicey. Lanugo, translucent skin, fused eyelids, a thick vernix coating, and the absence of fingernails are hallmarks of a previable infant. If the baby is clearly premature, very small, or has a less than optimal Apgar score, resuscitation proceeds in a stepwise manner with about 30 seconds devoted to each intervention before moving on to the next.
"Do each step well," Dr. McCullough said. "If you need more time to complete the components of an intervention, take it."
Not all newborns require suctioning. If the amniotic fluid is clear, limit suctioning to those who have obvious respiratory difficulty. If the fluid is meconium stained, the baby is at risk for meconium aspiration syndrome and suctioning is a must.
After addressing respiration, evaluate the infant for apnea, gasping, and labored breathing. There isn’t time to wait for a pulse oximeter to sense the heart rate, she said. Get the device on quickly, but take out a stethoscope and check at the precordial site. Oxygen levels may look low for up to 10 minutes after birth, as the lungs continue to inflate. This means that cyanosis cannot be used as a guide for resuscitation. "A lack of cyanosis does not mean the child isn’t hypoxic. If the baby requires resuscitation, if cyanosis persists, or the baby needs oxygen or positive pressure for more than a few breaths, you have to use a pulse oximeter."
Although 100% oxygen might seem logical, studies continue to show that newborns do better when resuscitated with room air. "Hyperoxia from supplemental oxygen can injure tissues and organs because it promotes the formation of free radicals."
A 2004 Cochrane review determined that newborns resuscitated on room air were about 30% more likely to survive than those who had 100% oxygen. There were no significant between-group differences in hypoxic ischemia or 10-minute Apgar, and no significant differences later in adverse neurodeveopmental outcomes (Cochrane Database Syst Rev. 2004;3:CD002273).
"Initiate resuscitation with blended oxygen. One suggestion is 21% oxygen for newborns older than 30 weeks’ gestation and 30% for those younger than 30 weeks. If the heart rate stays below 60 after about 90 seconds, increase the oxygen to 100% until the heart rate recovers. If, after this, the infant is still apneic or gasping, or the heart rate is still low, start with positive pressure ventilation."
If, after another 30 seconds of positive pressure ventilation, the heart rate is still low, try readjusting the mask and repositioning the baby. If there’s still no good response, consider increasing the inflation pressure, but don’t go above the recommended limit of more than 40 cm H20 of pressure.
The next steps would be to move on to an alternative ventilation method, like intubation, and to initiate chest compressions. Give 100% oxygen during compressions and reassess after 20 seconds.
Epinephrine, volume expanders, naloxone, and sodium bicarbonate have never really been studied in newborns but may be considered as a last resort. The umbilical vein provides ready access. Intraosseous administration can also be considered.
If the baby simply doesn’t respond, with no heartbeat for 10 minutes after 10 minutes of resuscitation efforts, consider stopping the interventions. Some parents prefer to withhold resuscitation altogether if the infant is unlikely to survive long, especially in cases of extreme prematurity, chromosomal abnormalities, or anencephaly.
"If you’re not sure whether resuscitation is indicated or not, it’s much better to err on the side of trying," Dr. McCullough said. "You can always discontinue support after speaking with parents."
Dr. McCullough has no relevant conflicts of interest.
LAKE BUENA VISTA, FLA. – The best way to take advantage of a struggling newborn’s "Golden Minute" won’t be found in any schmaltzy pregnancy book.
"Dry ’em off and piss ’em off," Dr. Maureen McCollough said at a meeting sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics.
Delivery rooms have the ability to quickly mobilize the high-tech equipment that can mean the difference between life and death for these neonates. But not every baby is considerate enough to arrive under ideal circumstances, said Dr. McCullough, director of pediatric emergency medicine at the University of Southern California Medical Center, Los Angeles.
"Dad might have already delivered this baby in the car, or Mom comes in complaining of stomach pains and there’s a baby crowning right there in the emergency department. You need to be ready."
Dr. McCullough outlined the stepwise resuscitation algorithm endorsed by the American Academy of Pediatrics in its 2010 guidelines.
The algorithm starts with the basics. If the infant looks full term, is crying or breathing, and has good muscle tone, she probably won’t need much in the way of interventions. Dry and swaddle her and get her warm; Mom’s abdomen is the perfect place for this. If the baby is really small – less than 1,500 grams – turn to plastic wrap instead of a blanket. The impermeable barrier decreases heat loss through evaporation and holds more of the baby’s body heat in. If possible, raise the room temperature to around 79 , she advised.
"Hypothermia is associated with increased mortality," Dr McCullough said. In trying to warm herself, the hypothermic newborn increases her metabolic rate, leading to increased oxygen consumption.
Stimulation comes next. "Slapping or flicking the soles of the feet, rubbing the back, and drying and suctioning the baby is often enough to get things going."
If the baby looks preterm, things can get dicey. Lanugo, translucent skin, fused eyelids, a thick vernix coating, and the absence of fingernails are hallmarks of a previable infant. If the baby is clearly premature, very small, or has a less than optimal Apgar score, resuscitation proceeds in a stepwise manner with about 30 seconds devoted to each intervention before moving on to the next.
"Do each step well," Dr. McCullough said. "If you need more time to complete the components of an intervention, take it."
Not all newborns require suctioning. If the amniotic fluid is clear, limit suctioning to those who have obvious respiratory difficulty. If the fluid is meconium stained, the baby is at risk for meconium aspiration syndrome and suctioning is a must.
After addressing respiration, evaluate the infant for apnea, gasping, and labored breathing. There isn’t time to wait for a pulse oximeter to sense the heart rate, she said. Get the device on quickly, but take out a stethoscope and check at the precordial site. Oxygen levels may look low for up to 10 minutes after birth, as the lungs continue to inflate. This means that cyanosis cannot be used as a guide for resuscitation. "A lack of cyanosis does not mean the child isn’t hypoxic. If the baby requires resuscitation, if cyanosis persists, or the baby needs oxygen or positive pressure for more than a few breaths, you have to use a pulse oximeter."
Although 100% oxygen might seem logical, studies continue to show that newborns do better when resuscitated with room air. "Hyperoxia from supplemental oxygen can injure tissues and organs because it promotes the formation of free radicals."
A 2004 Cochrane review determined that newborns resuscitated on room air were about 30% more likely to survive than those who had 100% oxygen. There were no significant between-group differences in hypoxic ischemia or 10-minute Apgar, and no significant differences later in adverse neurodeveopmental outcomes (Cochrane Database Syst Rev. 2004;3:CD002273).
"Initiate resuscitation with blended oxygen. One suggestion is 21% oxygen for newborns older than 30 weeks’ gestation and 30% for those younger than 30 weeks. If the heart rate stays below 60 after about 90 seconds, increase the oxygen to 100% until the heart rate recovers. If, after this, the infant is still apneic or gasping, or the heart rate is still low, start with positive pressure ventilation."
If, after another 30 seconds of positive pressure ventilation, the heart rate is still low, try readjusting the mask and repositioning the baby. If there’s still no good response, consider increasing the inflation pressure, but don’t go above the recommended limit of more than 40 cm H20 of pressure.
The next steps would be to move on to an alternative ventilation method, like intubation, and to initiate chest compressions. Give 100% oxygen during compressions and reassess after 20 seconds.
Epinephrine, volume expanders, naloxone, and sodium bicarbonate have never really been studied in newborns but may be considered as a last resort. The umbilical vein provides ready access. Intraosseous administration can also be considered.
If the baby simply doesn’t respond, with no heartbeat for 10 minutes after 10 minutes of resuscitation efforts, consider stopping the interventions. Some parents prefer to withhold resuscitation altogether if the infant is unlikely to survive long, especially in cases of extreme prematurity, chromosomal abnormalities, or anencephaly.
"If you’re not sure whether resuscitation is indicated or not, it’s much better to err on the side of trying," Dr. McCullough said. "You can always discontinue support after speaking with parents."
Dr. McCullough has no relevant conflicts of interest.
LAKE BUENA VISTA, FLA. – The best way to take advantage of a struggling newborn’s "Golden Minute" won’t be found in any schmaltzy pregnancy book.
"Dry ’em off and piss ’em off," Dr. Maureen McCollough said at a meeting sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics.
Delivery rooms have the ability to quickly mobilize the high-tech equipment that can mean the difference between life and death for these neonates. But not every baby is considerate enough to arrive under ideal circumstances, said Dr. McCullough, director of pediatric emergency medicine at the University of Southern California Medical Center, Los Angeles.
"Dad might have already delivered this baby in the car, or Mom comes in complaining of stomach pains and there’s a baby crowning right there in the emergency department. You need to be ready."
Dr. McCullough outlined the stepwise resuscitation algorithm endorsed by the American Academy of Pediatrics in its 2010 guidelines.
The algorithm starts with the basics. If the infant looks full term, is crying or breathing, and has good muscle tone, she probably won’t need much in the way of interventions. Dry and swaddle her and get her warm; Mom’s abdomen is the perfect place for this. If the baby is really small – less than 1,500 grams – turn to plastic wrap instead of a blanket. The impermeable barrier decreases heat loss through evaporation and holds more of the baby’s body heat in. If possible, raise the room temperature to around 79 , she advised.
"Hypothermia is associated with increased mortality," Dr McCullough said. In trying to warm herself, the hypothermic newborn increases her metabolic rate, leading to increased oxygen consumption.
Stimulation comes next. "Slapping or flicking the soles of the feet, rubbing the back, and drying and suctioning the baby is often enough to get things going."
If the baby looks preterm, things can get dicey. Lanugo, translucent skin, fused eyelids, a thick vernix coating, and the absence of fingernails are hallmarks of a previable infant. If the baby is clearly premature, very small, or has a less than optimal Apgar score, resuscitation proceeds in a stepwise manner with about 30 seconds devoted to each intervention before moving on to the next.
"Do each step well," Dr. McCullough said. "If you need more time to complete the components of an intervention, take it."
Not all newborns require suctioning. If the amniotic fluid is clear, limit suctioning to those who have obvious respiratory difficulty. If the fluid is meconium stained, the baby is at risk for meconium aspiration syndrome and suctioning is a must.
After addressing respiration, evaluate the infant for apnea, gasping, and labored breathing. There isn’t time to wait for a pulse oximeter to sense the heart rate, she said. Get the device on quickly, but take out a stethoscope and check at the precordial site. Oxygen levels may look low for up to 10 minutes after birth, as the lungs continue to inflate. This means that cyanosis cannot be used as a guide for resuscitation. "A lack of cyanosis does not mean the child isn’t hypoxic. If the baby requires resuscitation, if cyanosis persists, or the baby needs oxygen or positive pressure for more than a few breaths, you have to use a pulse oximeter."
Although 100% oxygen might seem logical, studies continue to show that newborns do better when resuscitated with room air. "Hyperoxia from supplemental oxygen can injure tissues and organs because it promotes the formation of free radicals."
A 2004 Cochrane review determined that newborns resuscitated on room air were about 30% more likely to survive than those who had 100% oxygen. There were no significant between-group differences in hypoxic ischemia or 10-minute Apgar, and no significant differences later in adverse neurodeveopmental outcomes (Cochrane Database Syst Rev. 2004;3:CD002273).
"Initiate resuscitation with blended oxygen. One suggestion is 21% oxygen for newborns older than 30 weeks’ gestation and 30% for those younger than 30 weeks. If the heart rate stays below 60 after about 90 seconds, increase the oxygen to 100% until the heart rate recovers. If, after this, the infant is still apneic or gasping, or the heart rate is still low, start with positive pressure ventilation."
If, after another 30 seconds of positive pressure ventilation, the heart rate is still low, try readjusting the mask and repositioning the baby. If there’s still no good response, consider increasing the inflation pressure, but don’t go above the recommended limit of more than 40 cm H20 of pressure.
The next steps would be to move on to an alternative ventilation method, like intubation, and to initiate chest compressions. Give 100% oxygen during compressions and reassess after 20 seconds.
Epinephrine, volume expanders, naloxone, and sodium bicarbonate have never really been studied in newborns but may be considered as a last resort. The umbilical vein provides ready access. Intraosseous administration can also be considered.
If the baby simply doesn’t respond, with no heartbeat for 10 minutes after 10 minutes of resuscitation efforts, consider stopping the interventions. Some parents prefer to withhold resuscitation altogether if the infant is unlikely to survive long, especially in cases of extreme prematurity, chromosomal abnormalities, or anencephaly.
"If you’re not sure whether resuscitation is indicated or not, it’s much better to err on the side of trying," Dr. McCullough said. "You can always discontinue support after speaking with parents."
Dr. McCullough has no relevant conflicts of interest.
EXPERT ANALYSIS AT THE ADVANCED PEDIATRIC EMERGENCY MEDICINE ASSEMBLY
Consider developmental issues when treating teen sports injuries
BUENA VISTA, FLA – The cups and ribbons that young athletes bring home sometimes come with a price – injuries that can sideline them for a few games or haunt them for the rest of their lives.
Teenagers are more likely than adults to sustain sports injuries, Dr. Ilene Claudius said at a meeting sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics. Immature bones, strong tendons, and a general tendency to brush off aches and pains all conspire to increase the risk.
Open epiphyseal plates are always points of weakness on a growing bone, said Dr. Claudius of the University of Southern California, Los Angeles. "During periods of rapid growth, the epiphyses are incredibly weak, so boys in their early teens get a lot of sports injuries. They also have strong tendons that insert there and set those kids up for inflammation."
Most of these stress injuries occur in runners, jumpers, and dancers, she said – but they can be seen in those who play other sports. The risk is highest in two periods during a young athlete’s career – just as they delve enthusiastically into their sport and when they reach an elite level, during which time physical efforts grow even more demanding.
"Think about what that person has been doing that might predispose him to an injury: the couch potato who has been doing nothing for 12 years and then starts running every day, the elite athlete who excels in a sport and never deviates from that sport, or the athlete who has played a single sport for years and then takes up a new one, which uses an entirely different set of muscles and bones."
Muscles and bones grow rapidly to accommodate new activities, Dr. Claudius said. Muscles increase in mass and pull on bones, increasing bone mass. It takes a full 14 months for skeletal remodeling. But, in the meantime, when bone absorption outstrips bone repair, stress fractures can occur.
With some ice, rest, and NSAIDs, most of these injuries will heal within 8 weeks. Occasionally, stress fractures appear in more concerning places, like the navicular bone, femur, or femoral neck "These have a higher risk of complete fracture, so they need more aggressive treatment."
Gymnastics, football, and wrestling predispose athletes to hyperextension injuries. Symptoms include lower back pain that radiates to the buttocks and gets worse with exercise. Affected teens can present with paresthesia. These patients usually respond to a few months of activity modification and some physical therapy.
Repetitive hyperextension injuries can leave a lasting effect in the form of traction apophysitis, impingement of the spinous processes, or pseudoarthrosis of the transitional vertebrae.
Concussion is probably the most-feared sports injury. Every time an athlete sustains a concussion, the chances of getting another are increased and the time it takes to recover is extended.
Repeated head trauma can lead to a chronic traumatic encephalopathy. The latency period is 6-10 years, after which the athlete may begin to express emotional disorders, paranoia, memory problems, and even suicidal ideation. "Pathologically, it looks a lot like Alzheimer’s," Dr. Claudius said.
Concussion isn’t always easy to identify on the field or in the emergency department. Preseason neurocognitive testing can make diagnosis easier. "This gives you a baseline; if a concussion is present, the score typically decreases by 10% or more."
While adults typically return to normal in 4 or 5 days, research shows that young people have a much longer recovery time. For a teenager, up to 3 weeks or recovery is not unusual. Any kind of return to full play is absolutely contraindicated during recovery, and resting the brain is just as important as resting other parts of the body.
Cognitive rest can be a difficult concept for the teen to grasp. Dr. Claudius said. "We always need to tailor our message to the audience, and in this case, our audience is an adolescent. A week of cognitive rest means more than just a few days off school. It means not staying up late; it means no texting or video games. It means no sex."
When symptoms recede to mild – for example, sustained attention for 30 minutes without the return of somatic symptoms- the teen can take on a limited amount of school work. It’s important to get up out of bed and start returning to regular activities, with the exception of sports.
"They should avoid aerobic activity until they’re completely asymptomatic," Dr. Claudius said. "Then there can be a careful program that includes light aerobic exercise."
This should be followed by sport-specific training, then noncontact training, followed by full contact practice and, finally, returning to the game.
"Athletes should stay at each level until are completely asymptomatic for 24 hours. If they become symptomatic, they need to drop back to the prior level and stay there until they are."
Dr. Claudius had no financial disclosures.
BUENA VISTA, FLA – The cups and ribbons that young athletes bring home sometimes come with a price – injuries that can sideline them for a few games or haunt them for the rest of their lives.
Teenagers are more likely than adults to sustain sports injuries, Dr. Ilene Claudius said at a meeting sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics. Immature bones, strong tendons, and a general tendency to brush off aches and pains all conspire to increase the risk.
Open epiphyseal plates are always points of weakness on a growing bone, said Dr. Claudius of the University of Southern California, Los Angeles. "During periods of rapid growth, the epiphyses are incredibly weak, so boys in their early teens get a lot of sports injuries. They also have strong tendons that insert there and set those kids up for inflammation."
Most of these stress injuries occur in runners, jumpers, and dancers, she said – but they can be seen in those who play other sports. The risk is highest in two periods during a young athlete’s career – just as they delve enthusiastically into their sport and when they reach an elite level, during which time physical efforts grow even more demanding.
"Think about what that person has been doing that might predispose him to an injury: the couch potato who has been doing nothing for 12 years and then starts running every day, the elite athlete who excels in a sport and never deviates from that sport, or the athlete who has played a single sport for years and then takes up a new one, which uses an entirely different set of muscles and bones."
Muscles and bones grow rapidly to accommodate new activities, Dr. Claudius said. Muscles increase in mass and pull on bones, increasing bone mass. It takes a full 14 months for skeletal remodeling. But, in the meantime, when bone absorption outstrips bone repair, stress fractures can occur.
With some ice, rest, and NSAIDs, most of these injuries will heal within 8 weeks. Occasionally, stress fractures appear in more concerning places, like the navicular bone, femur, or femoral neck "These have a higher risk of complete fracture, so they need more aggressive treatment."
Gymnastics, football, and wrestling predispose athletes to hyperextension injuries. Symptoms include lower back pain that radiates to the buttocks and gets worse with exercise. Affected teens can present with paresthesia. These patients usually respond to a few months of activity modification and some physical therapy.
Repetitive hyperextension injuries can leave a lasting effect in the form of traction apophysitis, impingement of the spinous processes, or pseudoarthrosis of the transitional vertebrae.
Concussion is probably the most-feared sports injury. Every time an athlete sustains a concussion, the chances of getting another are increased and the time it takes to recover is extended.
Repeated head trauma can lead to a chronic traumatic encephalopathy. The latency period is 6-10 years, after which the athlete may begin to express emotional disorders, paranoia, memory problems, and even suicidal ideation. "Pathologically, it looks a lot like Alzheimer’s," Dr. Claudius said.
Concussion isn’t always easy to identify on the field or in the emergency department. Preseason neurocognitive testing can make diagnosis easier. "This gives you a baseline; if a concussion is present, the score typically decreases by 10% or more."
While adults typically return to normal in 4 or 5 days, research shows that young people have a much longer recovery time. For a teenager, up to 3 weeks or recovery is not unusual. Any kind of return to full play is absolutely contraindicated during recovery, and resting the brain is just as important as resting other parts of the body.
Cognitive rest can be a difficult concept for the teen to grasp. Dr. Claudius said. "We always need to tailor our message to the audience, and in this case, our audience is an adolescent. A week of cognitive rest means more than just a few days off school. It means not staying up late; it means no texting or video games. It means no sex."
When symptoms recede to mild – for example, sustained attention for 30 minutes without the return of somatic symptoms- the teen can take on a limited amount of school work. It’s important to get up out of bed and start returning to regular activities, with the exception of sports.
"They should avoid aerobic activity until they’re completely asymptomatic," Dr. Claudius said. "Then there can be a careful program that includes light aerobic exercise."
This should be followed by sport-specific training, then noncontact training, followed by full contact practice and, finally, returning to the game.
"Athletes should stay at each level until are completely asymptomatic for 24 hours. If they become symptomatic, they need to drop back to the prior level and stay there until they are."
Dr. Claudius had no financial disclosures.
BUENA VISTA, FLA – The cups and ribbons that young athletes bring home sometimes come with a price – injuries that can sideline them for a few games or haunt them for the rest of their lives.
Teenagers are more likely than adults to sustain sports injuries, Dr. Ilene Claudius said at a meeting sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics. Immature bones, strong tendons, and a general tendency to brush off aches and pains all conspire to increase the risk.
Open epiphyseal plates are always points of weakness on a growing bone, said Dr. Claudius of the University of Southern California, Los Angeles. "During periods of rapid growth, the epiphyses are incredibly weak, so boys in their early teens get a lot of sports injuries. They also have strong tendons that insert there and set those kids up for inflammation."
Most of these stress injuries occur in runners, jumpers, and dancers, she said – but they can be seen in those who play other sports. The risk is highest in two periods during a young athlete’s career – just as they delve enthusiastically into their sport and when they reach an elite level, during which time physical efforts grow even more demanding.
"Think about what that person has been doing that might predispose him to an injury: the couch potato who has been doing nothing for 12 years and then starts running every day, the elite athlete who excels in a sport and never deviates from that sport, or the athlete who has played a single sport for years and then takes up a new one, which uses an entirely different set of muscles and bones."
Muscles and bones grow rapidly to accommodate new activities, Dr. Claudius said. Muscles increase in mass and pull on bones, increasing bone mass. It takes a full 14 months for skeletal remodeling. But, in the meantime, when bone absorption outstrips bone repair, stress fractures can occur.
With some ice, rest, and NSAIDs, most of these injuries will heal within 8 weeks. Occasionally, stress fractures appear in more concerning places, like the navicular bone, femur, or femoral neck "These have a higher risk of complete fracture, so they need more aggressive treatment."
Gymnastics, football, and wrestling predispose athletes to hyperextension injuries. Symptoms include lower back pain that radiates to the buttocks and gets worse with exercise. Affected teens can present with paresthesia. These patients usually respond to a few months of activity modification and some physical therapy.
Repetitive hyperextension injuries can leave a lasting effect in the form of traction apophysitis, impingement of the spinous processes, or pseudoarthrosis of the transitional vertebrae.
Concussion is probably the most-feared sports injury. Every time an athlete sustains a concussion, the chances of getting another are increased and the time it takes to recover is extended.
Repeated head trauma can lead to a chronic traumatic encephalopathy. The latency period is 6-10 years, after which the athlete may begin to express emotional disorders, paranoia, memory problems, and even suicidal ideation. "Pathologically, it looks a lot like Alzheimer’s," Dr. Claudius said.
Concussion isn’t always easy to identify on the field or in the emergency department. Preseason neurocognitive testing can make diagnosis easier. "This gives you a baseline; if a concussion is present, the score typically decreases by 10% or more."
While adults typically return to normal in 4 or 5 days, research shows that young people have a much longer recovery time. For a teenager, up to 3 weeks or recovery is not unusual. Any kind of return to full play is absolutely contraindicated during recovery, and resting the brain is just as important as resting other parts of the body.
Cognitive rest can be a difficult concept for the teen to grasp. Dr. Claudius said. "We always need to tailor our message to the audience, and in this case, our audience is an adolescent. A week of cognitive rest means more than just a few days off school. It means not staying up late; it means no texting or video games. It means no sex."
When symptoms recede to mild – for example, sustained attention for 30 minutes without the return of somatic symptoms- the teen can take on a limited amount of school work. It’s important to get up out of bed and start returning to regular activities, with the exception of sports.
"They should avoid aerobic activity until they’re completely asymptomatic," Dr. Claudius said. "Then there can be a careful program that includes light aerobic exercise."
This should be followed by sport-specific training, then noncontact training, followed by full contact practice and, finally, returning to the game.
"Athletes should stay at each level until are completely asymptomatic for 24 hours. If they become symptomatic, they need to drop back to the prior level and stay there until they are."
Dr. Claudius had no financial disclosures.
EXPERT ANALYSIS AT THE ADVANCED PEDIATRIC EMERGENCY MEDICINE ASSEMBLY
Infant UTI: Spinal tap for meningitis before ED discharge
LAKE BUENA VISTA, FLA. – Does every baby who presents to the emergency department with a urinary tract infection need a lumbar puncture to rule out meningitis?
Maybe not, Dr. James Callahan said at the Advanced Pediatric Emergency Medicine Assembly. Age, past medical history, and the child’s overall demeanor are the best clues as to whether to proceed with a spinal tap in babies with a confirmed source of infection.
The topic is worth reviewing because childhood meningitis cases are on the decline, said Dr. Callahan of Children’s Hospital of Pennsylvania, Philadelphia.
When a disease begins to fade from a patient population, it also can fade from the collective consciousness of clinicians. "There are residents and fellows in emergency medicine and pediatrics now who have never seen a case of [Haemophilus] influenzae meningitis," he said at the meeting, which was sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics.
That can mean tragedy for patients and families, and disaster for doctors. "Missed meningitis remains the number-one cause of settled lawsuits in pediatric emergency medicine, and carries the highest settlement and indemnity costs," he said.
A number of signs can help rule in the disease, but few can completely rule it out. "Although several clinical features are useful in diagnosing meningitis, no one isolated clinical feature is diagnostic. Nor can any isolated clinical feature completely exclude meningitis as a diagnostic possibility, and it’s not clear what the most accurate combination of clinical features is – or if there even is such a combination," Dr. Callahan explained.
That leaves clinicians with what seems to be the only concrete option – the lumbar puncture. "I personally think an LP is a relatively simple procedure, but there is a lot of parental resistance to it," he noted.
Dr. Callahan examined the question in light of infants’ most common bacterial infection – the urinary tract infection (UTI). Studies from the last 15 years agree that, while the risk of meningitis in conjunction with UTI is very low, it is there.
The largest of these included nearly 2,000 infants with culture-proven UTI. Most (1,609) underwent an LP. Of those patients, 3% had bacterial meningitis. A combination of clinical findings – not clinically ill on exam, no dehydration or acute respiratory distress, no concomitant acute disease or high-risk medical history – ruled out meningitis with a 98% sensitivity and 99.9% negative predictive value (Pediatrics 2010;126:1074-83).
A 2011 study found a 1% rate of meningitis associated with UTI in infants younger than 28 days, but there were no cases at all in the older babies. All of those with meningitis were symptomatic on admission, with fever, irritability, and lethargy (PLoS One 2011;6:e26576).
"Meningitis appears exceedingly rare in children older than 28 days," Dr. Callahan said. "All neonates who present with a culture-proven UTI should have an LP. But those who are older, and who look well, without a negative past history – you might consider not doing one."
Whether or not the child will be admitted to the hospital plays a part in Dr. Callahan’s decision.
"If they have a UTI and they’re getting admitted, but look well and have a negative past medical history, I don’t tap. I really think the data say if they look like they are well, they will not get meningitis."
If, on the other hand, the baby will be going home from the emergency visit, he does the procedure. "And make sure you have someone who’s going to follow that child very closely," he advised.
Dr. Callahan had no financial disclosures.
LAKE BUENA VISTA, FLA. – Does every baby who presents to the emergency department with a urinary tract infection need a lumbar puncture to rule out meningitis?
Maybe not, Dr. James Callahan said at the Advanced Pediatric Emergency Medicine Assembly. Age, past medical history, and the child’s overall demeanor are the best clues as to whether to proceed with a spinal tap in babies with a confirmed source of infection.
The topic is worth reviewing because childhood meningitis cases are on the decline, said Dr. Callahan of Children’s Hospital of Pennsylvania, Philadelphia.
When a disease begins to fade from a patient population, it also can fade from the collective consciousness of clinicians. "There are residents and fellows in emergency medicine and pediatrics now who have never seen a case of [Haemophilus] influenzae meningitis," he said at the meeting, which was sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics.
That can mean tragedy for patients and families, and disaster for doctors. "Missed meningitis remains the number-one cause of settled lawsuits in pediatric emergency medicine, and carries the highest settlement and indemnity costs," he said.
A number of signs can help rule in the disease, but few can completely rule it out. "Although several clinical features are useful in diagnosing meningitis, no one isolated clinical feature is diagnostic. Nor can any isolated clinical feature completely exclude meningitis as a diagnostic possibility, and it’s not clear what the most accurate combination of clinical features is – or if there even is such a combination," Dr. Callahan explained.
That leaves clinicians with what seems to be the only concrete option – the lumbar puncture. "I personally think an LP is a relatively simple procedure, but there is a lot of parental resistance to it," he noted.
Dr. Callahan examined the question in light of infants’ most common bacterial infection – the urinary tract infection (UTI). Studies from the last 15 years agree that, while the risk of meningitis in conjunction with UTI is very low, it is there.
The largest of these included nearly 2,000 infants with culture-proven UTI. Most (1,609) underwent an LP. Of those patients, 3% had bacterial meningitis. A combination of clinical findings – not clinically ill on exam, no dehydration or acute respiratory distress, no concomitant acute disease or high-risk medical history – ruled out meningitis with a 98% sensitivity and 99.9% negative predictive value (Pediatrics 2010;126:1074-83).
A 2011 study found a 1% rate of meningitis associated with UTI in infants younger than 28 days, but there were no cases at all in the older babies. All of those with meningitis were symptomatic on admission, with fever, irritability, and lethargy (PLoS One 2011;6:e26576).
"Meningitis appears exceedingly rare in children older than 28 days," Dr. Callahan said. "All neonates who present with a culture-proven UTI should have an LP. But those who are older, and who look well, without a negative past history – you might consider not doing one."
Whether or not the child will be admitted to the hospital plays a part in Dr. Callahan’s decision.
"If they have a UTI and they’re getting admitted, but look well and have a negative past medical history, I don’t tap. I really think the data say if they look like they are well, they will not get meningitis."
If, on the other hand, the baby will be going home from the emergency visit, he does the procedure. "And make sure you have someone who’s going to follow that child very closely," he advised.
Dr. Callahan had no financial disclosures.
LAKE BUENA VISTA, FLA. – Does every baby who presents to the emergency department with a urinary tract infection need a lumbar puncture to rule out meningitis?
Maybe not, Dr. James Callahan said at the Advanced Pediatric Emergency Medicine Assembly. Age, past medical history, and the child’s overall demeanor are the best clues as to whether to proceed with a spinal tap in babies with a confirmed source of infection.
The topic is worth reviewing because childhood meningitis cases are on the decline, said Dr. Callahan of Children’s Hospital of Pennsylvania, Philadelphia.
When a disease begins to fade from a patient population, it also can fade from the collective consciousness of clinicians. "There are residents and fellows in emergency medicine and pediatrics now who have never seen a case of [Haemophilus] influenzae meningitis," he said at the meeting, which was sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics.
That can mean tragedy for patients and families, and disaster for doctors. "Missed meningitis remains the number-one cause of settled lawsuits in pediatric emergency medicine, and carries the highest settlement and indemnity costs," he said.
A number of signs can help rule in the disease, but few can completely rule it out. "Although several clinical features are useful in diagnosing meningitis, no one isolated clinical feature is diagnostic. Nor can any isolated clinical feature completely exclude meningitis as a diagnostic possibility, and it’s not clear what the most accurate combination of clinical features is – or if there even is such a combination," Dr. Callahan explained.
That leaves clinicians with what seems to be the only concrete option – the lumbar puncture. "I personally think an LP is a relatively simple procedure, but there is a lot of parental resistance to it," he noted.
Dr. Callahan examined the question in light of infants’ most common bacterial infection – the urinary tract infection (UTI). Studies from the last 15 years agree that, while the risk of meningitis in conjunction with UTI is very low, it is there.
The largest of these included nearly 2,000 infants with culture-proven UTI. Most (1,609) underwent an LP. Of those patients, 3% had bacterial meningitis. A combination of clinical findings – not clinically ill on exam, no dehydration or acute respiratory distress, no concomitant acute disease or high-risk medical history – ruled out meningitis with a 98% sensitivity and 99.9% negative predictive value (Pediatrics 2010;126:1074-83).
A 2011 study found a 1% rate of meningitis associated with UTI in infants younger than 28 days, but there were no cases at all in the older babies. All of those with meningitis were symptomatic on admission, with fever, irritability, and lethargy (PLoS One 2011;6:e26576).
"Meningitis appears exceedingly rare in children older than 28 days," Dr. Callahan said. "All neonates who present with a culture-proven UTI should have an LP. But those who are older, and who look well, without a negative past history – you might consider not doing one."
Whether or not the child will be admitted to the hospital plays a part in Dr. Callahan’s decision.
"If they have a UTI and they’re getting admitted, but look well and have a negative past medical history, I don’t tap. I really think the data say if they look like they are well, they will not get meningitis."
If, on the other hand, the baby will be going home from the emergency visit, he does the procedure. "And make sure you have someone who’s going to follow that child very closely," he advised.
Dr. Callahan had no financial disclosures.
EXPERT ANALYSIS FROM THE ADVANCED PEDIATRIC EMERGENCY MEDICINE ASSEMBLY
Kids and clots: Expecting the unexpected
LAKE BUENA VISTA, FLA. – Venous thromboembolism is "not that uncommon in children" and seems to be on the rise, Dr. James Callahan said at the Advanced Pediatric Emergency Medicine Assembly.
In the general pediatric population, annual incidence is around 1 per 100,000. In hospitalized children, the number is much higher – up to 57 per 100,000. Rates of pulmonary embolism and deep vein thrombosis have increased markedly over the past decade, said Dr. Callahan of the Children’s Hospital of Philadelphia.
"National hospital discharge data show that the disorders increased by about 70% from 2001 to 2007, and other studies show similar increases in other countries," he noted.
Although no one really knows the reason behind this increase, it’s probably linked to better medical care for children with chronic illness. "As we keep children with more and more complex diseases alive longer and longer, we’re going to keep seeing this trend," he said at the meeting, which was sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics.
VTEs can be harder to recognize in children than in adults. The symptoms can be subtle and nonspecific. When signs and symptoms do occur, Dr. Callahan said, "we may not have PEs and DVTs high on the list of possibilities for children, so we can miss them. Sometimes it takes a while to figure it out. In autopsy studies, up to 4% of children showed signs of a pulmonary embolism or DVT. Only half of them had any symptoms at all, and a DVT was suspected in only about 15%."
Risk peaks at two times during a child’s life: in babies younger than 1 year and in older teens. In infants, the incidence is often linked to prematurity and the need for an indwelling catheter. The second peak is in teens around 15-18 years old who don’t have any underlying illness. These cases account for about 50% of childhood DVTs. In older children, the pathophysiology is similar to what’s seen in adults – they have some circulatory stasis, get a clot, and it breaks off.
A minority of children who develop a DVT or PE have some chronic predisposing illness – often a thrombophilia, but renal disease, systemic lupus erythematosus, and even some medications also can be underlying culprits. The indwelling line remains the single biggest risk factor for children of all ages.
Pleuritic chest pain, the most common symptom, is present in up to 84% of cases. The incidence of dyspnea, at 58%, is much lower than in adult patients. About half of children with a VTE will cough, and about a third show hemoptysis. Children are likely to be hypoxemic and tachypneic, run a fever, and have abnormal breath sounds and increased second heart sound.
Hypoxemia can be a very telltale sign. "If I see that in a child in the absence of pneumonia, I start to get worried. If I see an adolescent who presents with unexplained pleuritic chest pain, dyspnea, hypoxemia, and one risk or more of the risk factors, I go looking for it," Dr. Callahan said.
The Wells criteria – a classic risk stratification system for adults – just don’t work in children. "Even if you change the numbers to make it age specific, it’s not really helpful," he said.
Sinus tachycardia is the most reliable cardiac sign for pulmonary embolism in a child, but the ECG is completely normal in up to 25%. D-dimer levels are helpful in adults but have never been validated in children. A ventilation/perfusion scan is useful in otherwise healthy children, but "many of these kids have underlying disease, and that can make it inaccurate," he pointed out.
CT angiography is probably the most reliable diagnostic tool. "The scan is quick, which is good, but the child has to be immobilized and you need at least a 22G intravenous cannula and may need a 20G," Dr. Callahan said.
The treatment approach for children is also different than it is for adults, Dr. Callahan said. "There are no good studies on thrombolysis for children, but in certain cases – such as a massive PE with hemodynamic instability – it can be considered."
There are strict contraindications, however, including major surgery needed within 7-10 days; active bleeding; surgery on the central nervous system; ischemia, trauma, or hemorrhage within the past 30 days; recent seizures; a low platelet count and fibrinogen level; and uncontrolled hypertension.
Tissue plasminogen activator has not been well studied in pediatric populations and isn’t indicated for use in children, but it is often used off label. Low-molecular-weight heparin has become the treatment of choice for most. Its longer half-life and more predictable response make it a good choice for children, who will also need less frequent monitoring.
"Neither low-molecular-weight nor unfractionated heparin should ever be used in children with heparin-induced thrombocytopenia," Dr. Callahan said. "In this setting, one of the newer anticoagulants, such as direct thrombin or selective Xa inhibitors, should be used."
About 10% of children with a clot will die, but mortality is highly associated with underlying disease. Children who do survive have a risk of recurrence and an increased risk of death with each recurrence.
Dr. Callahan had no financial disclosures.
This article on venous thromboembolism is a welcome reminder of a condition that is taught extensively in residency but may be quickly forgotten.
 |
| Dr. Francine Pearce |
Many of us can remember the dreadful task of creating a long differential diagnosis list when a case was to be presented. Though daunting, that task assisted our ability to think broadly and to include all possible disease states and avert unwanted outcomes. VTE’s subtle presentation was always included on this list. Commonly, VTE is presented in the case scenario of the teenager on birth control pills or after a fracture leading to prolonged immobility. What separates the astute physician is the ability to consider this diagnosis in the less familiar scenario.
Dr. Callahan identified the common pre-existing conditions that VTE should always be considered. Listing the subtle signs and symptoms was a helpful reminder to increase one’s suspicion in less common presentations. And a clear algorithm was presented to determine the appropriate indications to proceed to the CT angiography, which is an expensive invasive test, and should be used judiciously. This information will certainly improve clinical practice.
Dr. Pearce, a former hospitalist, is a pediatrician in Frankfort, Ill.
This article on venous thromboembolism is a welcome reminder of a condition that is taught extensively in residency but may be quickly forgotten.
|
| Dr. Francine Pearce |
Many of us can remember the dreadful task of creating a long differential diagnosis list when a case was to be presented. Though daunting, that task assisted our ability to think broadly and to include all possible disease states and avert unwanted outcomes. VTE’s subtle presentation was always included on this list. Commonly, VTE is presented in the case scenario of the teenager on birth control pills or after a fracture leading to prolonged immobility. What separates the astute physician is the ability to consider this diagnosis in the less familiar scenario.
Dr. Callahan identified the common pre-existing conditions that VTE should always be considered. Listing the subtle signs and symptoms was a helpful reminder to increase one’s suspicion in less common presentations. And a clear algorithm was presented to determine the appropriate indications to proceed to the CT angiography, which is an expensive invasive test, and should be used judiciously. This information will certainly improve clinical practice.
Dr. Pearce, a former hospitalist, is a pediatrician in Frankfort, Ill.
This article on venous thromboembolism is a welcome reminder of a condition that is taught extensively in residency but may be quickly forgotten.
|
| Dr. Francine Pearce |
Many of us can remember the dreadful task of creating a long differential diagnosis list when a case was to be presented. Though daunting, that task assisted our ability to think broadly and to include all possible disease states and avert unwanted outcomes. VTE’s subtle presentation was always included on this list. Commonly, VTE is presented in the case scenario of the teenager on birth control pills or after a fracture leading to prolonged immobility. What separates the astute physician is the ability to consider this diagnosis in the less familiar scenario.
Dr. Callahan identified the common pre-existing conditions that VTE should always be considered. Listing the subtle signs and symptoms was a helpful reminder to increase one’s suspicion in less common presentations. And a clear algorithm was presented to determine the appropriate indications to proceed to the CT angiography, which is an expensive invasive test, and should be used judiciously. This information will certainly improve clinical practice.
Dr. Pearce, a former hospitalist, is a pediatrician in Frankfort, Ill.
LAKE BUENA VISTA, FLA. – Venous thromboembolism is "not that uncommon in children" and seems to be on the rise, Dr. James Callahan said at the Advanced Pediatric Emergency Medicine Assembly.
In the general pediatric population, annual incidence is around 1 per 100,000. In hospitalized children, the number is much higher – up to 57 per 100,000. Rates of pulmonary embolism and deep vein thrombosis have increased markedly over the past decade, said Dr. Callahan of the Children’s Hospital of Philadelphia.
"National hospital discharge data show that the disorders increased by about 70% from 2001 to 2007, and other studies show similar increases in other countries," he noted.
Although no one really knows the reason behind this increase, it’s probably linked to better medical care for children with chronic illness. "As we keep children with more and more complex diseases alive longer and longer, we’re going to keep seeing this trend," he said at the meeting, which was sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics.
VTEs can be harder to recognize in children than in adults. The symptoms can be subtle and nonspecific. When signs and symptoms do occur, Dr. Callahan said, "we may not have PEs and DVTs high on the list of possibilities for children, so we can miss them. Sometimes it takes a while to figure it out. In autopsy studies, up to 4% of children showed signs of a pulmonary embolism or DVT. Only half of them had any symptoms at all, and a DVT was suspected in only about 15%."
Risk peaks at two times during a child’s life: in babies younger than 1 year and in older teens. In infants, the incidence is often linked to prematurity and the need for an indwelling catheter. The second peak is in teens around 15-18 years old who don’t have any underlying illness. These cases account for about 50% of childhood DVTs. In older children, the pathophysiology is similar to what’s seen in adults – they have some circulatory stasis, get a clot, and it breaks off.
A minority of children who develop a DVT or PE have some chronic predisposing illness – often a thrombophilia, but renal disease, systemic lupus erythematosus, and even some medications also can be underlying culprits. The indwelling line remains the single biggest risk factor for children of all ages.
Pleuritic chest pain, the most common symptom, is present in up to 84% of cases. The incidence of dyspnea, at 58%, is much lower than in adult patients. About half of children with a VTE will cough, and about a third show hemoptysis. Children are likely to be hypoxemic and tachypneic, run a fever, and have abnormal breath sounds and increased second heart sound.
Hypoxemia can be a very telltale sign. "If I see that in a child in the absence of pneumonia, I start to get worried. If I see an adolescent who presents with unexplained pleuritic chest pain, dyspnea, hypoxemia, and one risk or more of the risk factors, I go looking for it," Dr. Callahan said.
The Wells criteria – a classic risk stratification system for adults – just don’t work in children. "Even if you change the numbers to make it age specific, it’s not really helpful," he said.
Sinus tachycardia is the most reliable cardiac sign for pulmonary embolism in a child, but the ECG is completely normal in up to 25%. D-dimer levels are helpful in adults but have never been validated in children. A ventilation/perfusion scan is useful in otherwise healthy children, but "many of these kids have underlying disease, and that can make it inaccurate," he pointed out.
CT angiography is probably the most reliable diagnostic tool. "The scan is quick, which is good, but the child has to be immobilized and you need at least a 22G intravenous cannula and may need a 20G," Dr. Callahan said.
The treatment approach for children is also different than it is for adults, Dr. Callahan said. "There are no good studies on thrombolysis for children, but in certain cases – such as a massive PE with hemodynamic instability – it can be considered."
There are strict contraindications, however, including major surgery needed within 7-10 days; active bleeding; surgery on the central nervous system; ischemia, trauma, or hemorrhage within the past 30 days; recent seizures; a low platelet count and fibrinogen level; and uncontrolled hypertension.
Tissue plasminogen activator has not been well studied in pediatric populations and isn’t indicated for use in children, but it is often used off label. Low-molecular-weight heparin has become the treatment of choice for most. Its longer half-life and more predictable response make it a good choice for children, who will also need less frequent monitoring.
"Neither low-molecular-weight nor unfractionated heparin should ever be used in children with heparin-induced thrombocytopenia," Dr. Callahan said. "In this setting, one of the newer anticoagulants, such as direct thrombin or selective Xa inhibitors, should be used."
About 10% of children with a clot will die, but mortality is highly associated with underlying disease. Children who do survive have a risk of recurrence and an increased risk of death with each recurrence.
Dr. Callahan had no financial disclosures.
LAKE BUENA VISTA, FLA. – Venous thromboembolism is "not that uncommon in children" and seems to be on the rise, Dr. James Callahan said at the Advanced Pediatric Emergency Medicine Assembly.
In the general pediatric population, annual incidence is around 1 per 100,000. In hospitalized children, the number is much higher – up to 57 per 100,000. Rates of pulmonary embolism and deep vein thrombosis have increased markedly over the past decade, said Dr. Callahan of the Children’s Hospital of Philadelphia.
"National hospital discharge data show that the disorders increased by about 70% from 2001 to 2007, and other studies show similar increases in other countries," he noted.
Although no one really knows the reason behind this increase, it’s probably linked to better medical care for children with chronic illness. "As we keep children with more and more complex diseases alive longer and longer, we’re going to keep seeing this trend," he said at the meeting, which was sponsored by the American College of Emergency Physicians and the American Academy of Pediatrics.
VTEs can be harder to recognize in children than in adults. The symptoms can be subtle and nonspecific. When signs and symptoms do occur, Dr. Callahan said, "we may not have PEs and DVTs high on the list of possibilities for children, so we can miss them. Sometimes it takes a while to figure it out. In autopsy studies, up to 4% of children showed signs of a pulmonary embolism or DVT. Only half of them had any symptoms at all, and a DVT was suspected in only about 15%."
Risk peaks at two times during a child’s life: in babies younger than 1 year and in older teens. In infants, the incidence is often linked to prematurity and the need for an indwelling catheter. The second peak is in teens around 15-18 years old who don’t have any underlying illness. These cases account for about 50% of childhood DVTs. In older children, the pathophysiology is similar to what’s seen in adults – they have some circulatory stasis, get a clot, and it breaks off.
A minority of children who develop a DVT or PE have some chronic predisposing illness – often a thrombophilia, but renal disease, systemic lupus erythematosus, and even some medications also can be underlying culprits. The indwelling line remains the single biggest risk factor for children of all ages.
Pleuritic chest pain, the most common symptom, is present in up to 84% of cases. The incidence of dyspnea, at 58%, is much lower than in adult patients. About half of children with a VTE will cough, and about a third show hemoptysis. Children are likely to be hypoxemic and tachypneic, run a fever, and have abnormal breath sounds and increased second heart sound.
Hypoxemia can be a very telltale sign. "If I see that in a child in the absence of pneumonia, I start to get worried. If I see an adolescent who presents with unexplained pleuritic chest pain, dyspnea, hypoxemia, and one risk or more of the risk factors, I go looking for it," Dr. Callahan said.
The Wells criteria – a classic risk stratification system for adults – just don’t work in children. "Even if you change the numbers to make it age specific, it’s not really helpful," he said.
Sinus tachycardia is the most reliable cardiac sign for pulmonary embolism in a child, but the ECG is completely normal in up to 25%. D-dimer levels are helpful in adults but have never been validated in children. A ventilation/perfusion scan is useful in otherwise healthy children, but "many of these kids have underlying disease, and that can make it inaccurate," he pointed out.
CT angiography is probably the most reliable diagnostic tool. "The scan is quick, which is good, but the child has to be immobilized and you need at least a 22G intravenous cannula and may need a 20G," Dr. Callahan said.
The treatment approach for children is also different than it is for adults, Dr. Callahan said. "There are no good studies on thrombolysis for children, but in certain cases – such as a massive PE with hemodynamic instability – it can be considered."
There are strict contraindications, however, including major surgery needed within 7-10 days; active bleeding; surgery on the central nervous system; ischemia, trauma, or hemorrhage within the past 30 days; recent seizures; a low platelet count and fibrinogen level; and uncontrolled hypertension.
Tissue plasminogen activator has not been well studied in pediatric populations and isn’t indicated for use in children, but it is often used off label. Low-molecular-weight heparin has become the treatment of choice for most. Its longer half-life and more predictable response make it a good choice for children, who will also need less frequent monitoring.
"Neither low-molecular-weight nor unfractionated heparin should ever be used in children with heparin-induced thrombocytopenia," Dr. Callahan said. "In this setting, one of the newer anticoagulants, such as direct thrombin or selective Xa inhibitors, should be used."
About 10% of children with a clot will die, but mortality is highly associated with underlying disease. Children who do survive have a risk of recurrence and an increased risk of death with each recurrence.
Dr. Callahan had no financial disclosures.
EXPERT ANALYSIS FROM THE ADVANCED PEDIATRIC EMERGENCY MEDICINE ASSEMBLY
Integrating palliative care in the ED
As physicians and hospitals increase their focus on palliative care programs, many are still wary about the practice. At the 2013 Advanced Pediatric Emergency Medicine Assembly, Dr. Patricia O'Malley, director of pediatric palliative care services at Massachusetts General Hospital, said palliative care in the emergency department is critical, and physicians should use a focused approach when initiating these difficult conversations.
As physicians and hospitals increase their focus on palliative care programs, many are still wary about the practice. At the 2013 Advanced Pediatric Emergency Medicine Assembly, Dr. Patricia O'Malley, director of pediatric palliative care services at Massachusetts General Hospital, said palliative care in the emergency department is critical, and physicians should use a focused approach when initiating these difficult conversations.
As physicians and hospitals increase their focus on palliative care programs, many are still wary about the practice. At the 2013 Advanced Pediatric Emergency Medicine Assembly, Dr. Patricia O'Malley, director of pediatric palliative care services at Massachusetts General Hospital, said palliative care in the emergency department is critical, and physicians should use a focused approach when initiating these difficult conversations.