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Often clinicians shy away from caring for children, because of the notion that “they aren’t little adults.” We have previously discussed my disdain for this mantra. They are not aliens! They do, however, have different anatomy and physiology that must be taken into consideration. What makes children even more exciting (AKA challenging) to care for is that these differences evolve and change as they grow older. We see this most obviously with respect to Trauma. Take facial trauma for example. Nasal fractures in kids need to be approached differently than in adults. Actually, all of the changing anatomy of a child affects facial fractures considerably. Let us take a minute to digest a morsel of knowledge on Pediatric Facial Fractures and Age:

Facial Fractures: Basics
  • Facial Fractures occur less commonly in children than adults.
    • ~5-15% of all facial fractures are seen in children. [Alcala-Galiano, 2008]
    • Lowest rates in infants and increases with age.
  • Two peaks in frequency of facial fractures: [Alcala-Galiano, 2008]
    • 6-7 years of age (early school age)
    • 12-14 years of age (increased sports participation… and being adolescents)
  • Most common associated causes: [Alcala-Galiano, 2008]
    • Motor Vehicle Accidents – ~36% (because cars injure everyone all of the time!) [Wong, 2016; Costa Ferreira, 2016]
    • Sports Participation – ~26% (Kids colliding at high speeds, or throwing projectiles at each other)
    • Falls – ~23% (Gravity works always) [Oleck, 2019]
    • Interpersonal Violence – ~9% (’cause people are terrible to each other) [Hoppe, 2015; Hope, 2014]
  • Associated Injuries: [Alcala-Galiano, 2008]
    • Facial fractures are often associated with severe traumatic mechanisms. [Costa Ferreira, 2016]
    • As much as 88% will have associated injuries. [Alcala-Galiano, 2008]
    • Mid-face fractures can be associated with intra-cranial injury and cervical spine injury. [Hoppe, 2014]
    • Increased risk of associated injuries depends on type of facial fracture:
Facial Fractures: Changing Anatomy
  • Fracture patterns in children are similar to adults, BUT likelihood of specific injury patterns change due to anatomic factors.
  • There are 4 evolving anatomic factors that influence facial fracture frequency. [Alcala-Galiano, 2008]
  • Skull-to-Face ratio
    • Very young have prominent frontal skull protrusion with smaller facial features.
    • Frontal skull often “protects” the face from impact.
    • With increasing age, the face grows downward and forward, leading to the mid-face and mandible being the most prominent structures.
    • From birth to maturity, the cranium increases in size 4-fold, but the face increased 12-fold! [Alcala-Galiano, 2008]
  • Sinus Development
    • Pneumatization of the sinuses is an important factor. [Alcala-Galiano, 2008]
    • It progresses sequentially from the Ethmoids to the Maxillary sinuses, Sphenoid Sinuses, and ends with Frontal Sinuses.
    • Prior to pneumatization, the bone is more resistant to fracture.
    • After sinus development, the bone may fracture more easily, but that dissipates force (ie, cushions).
    • Maxillary and Frontal Sinus development are correlated with frequency of mid-face fractures.
  • Phase of Dentition
    • Dentition occurs in 3 stages.
      • Decidual phase (~ 2 years)
      • Mixed phase (6-12 years)
      • Permanent phase (>~12 years)
    • The un-erupted teeth (during decimal or mixed phase) add strength to the maxillary and mandible. [Alcala-Galiano, 2008]
  • Structure of Bone and Soft Tissues
    • Bones in children are more elastic and resistant to fracture than adults.
    • Higher likelihood of greenstick fractures in children. [Alcala-Galiano, 2008]
    • The elasticity of the surrounding soft tissues can lead to minimal external signs of injury. [Oleck, 2019]
Facial Fractures: Types
  • Orbital – 9% [Alcala-Galiano, 2008]
    • Rare in young children.
    • Once frontal sinus develops (~ 7 yrs), force is transmitted to the medial and lateral walls and floor of the orbit.
    • Orbital Fractures are often associated with other fractures! [Oleck, 2019]
    • Common fracture to look for is the Orbital Blowout fracture!
      • Floor is the least resistant bone.
      • May see enophthalmos.
      • Patient may have diplopia.
      • Look for Ocular injuries!
  • Frontal Skull – ~5% [Alcala-Galiano, 2008]
    • More common in younger children due to prominence of forehead.
    • In kids < ~7 yrs (frontal sinus has not developed), frontal fractures tend to affect the orbital roof!
    • Considered to be Skull Fractures at this age.
    • Increased risk for neurocranial injuries. [Alcala-Galiano, 2008]
  • Midface – ~3% [Alcala-Galiano, 2008]
    • Rare in young children.
    • Typically result from high-energy impacts.
    • Prevalence increases as maxillary sinuses develop and permanent teeth erupt.
    • Zymgomatic fractures are the most frequent fractures of the mid-face, but often greenstick fractures in children.
    • Can involve the orbital floor and walls.
  • Complex Naso-orbital (ie, Le Fort) [Alcala-Galiano, 2008]
    • Are least common – ~1%
    • Greatest potential for future deformity.
Moral of the Morsel
  • In the beginning, the Face is Protected. The large forehead will often take the brunt of the force.
  • With age, comes a Bigger Face! As the sinuses develop and the teeth erupt, and the face grows, it becomes more at risk.
  • Don’t just look for the fracture! There may be more associated injuries!
  • Don’t just stop with the injury. Ask why? Inter-personal violence is a problem that warrants our action.
References
Oleck NC, Dobitsch AA, Liu FC, Halsey JN, Le TT, Hoppe IC1, Lee ES, Granick MS. Traumatic Falls in the Pediatric Population: Facial Fracture Patterns Observed in a Leading Cause of Childhood Injury. Ann Plast Surg. 2019 Apr;82(4S Suppl 3):S195-S198. PMID: 30730318. [PubMed] [Read by QxMD] Falls are a leading cause of nonfatal injury in the pediatric population, resulting in numerous hospitalizations. Children may not have fully developed reflexive and balancing abilities, rendering them more susceptible to traumatic falls. Here the authors present their findings regarding patterns of facial fracture and concomitant injury seen in the pediatric population secondary to falls. […]
Reich W1, Aust O2, Eckert A3. Prospective analysis of mid-facial fractures in a single-center pediatric-adolescent cohort. Int J Pediatr Otorhinolaryngol. 2019 Apr;119:151-160. PMID: 30708183. [PubMed] [Read by QxMD] The complex architecture of the midface renders diagnosing and treating fractures challenging, especially for young patients who present the additional risk of suffering growth and development deficiencies, which is to be avoided at all costs. […]
Lee SH1, Yun SJ2, Ryu S1, Choi SW1, Kim HJ1, Kang TK1, Oh SC1, Cho SJ1. Brain Computed Tomography Compared with Facial 3-Dimensional Computed Tomography for Diagnosis of Facial Fractures. J Pediatr. 2017 May;184:32-37. PMID: 28190518. [PubMed] [Read by QxMD] To compare the detection of facial fractures and radiation dose between brain computed tomography (CT) and facial 3-dimensional (3D) CT in pediatric patients who have experienced a trauma. […]
Ferreira PC1, Barbosa J, Braga JM, Rodrigues A, Silva ÁC, Amarante JM. Pediatric Facial Fractures: A Review of 2071 Fractures. Ann Plast Surg. 2016 Jan;77(1):54-60. PMID: 25275475. [PubMed] [Read by QxMD] Facial fractures are infrequent in children and adolescents, and there are only few reports that review a significant number of patients. The objective of this study was to analyze the pattern of maxillofacial fractures in pediatric patients of Portugal. […]
Wong FK1, Adams S, Coates TJ, Hudson DA. Pediatric Facial Fractures. J Craniofac Surg. 2016 Jan;27(1):128-30. PMID: 26674891. [PubMed] [Read by QxMD] There are few published articles describing the epidemiology of facial fractures in South Africa, and there is only one published study in pediatric patients. […]
Hoppe IC1, Kordahi AM, Lee ES, Granick MS. Pediatric Facial Fractures: Interpersonal Violence as a Mechanism of Injury. J Craniofac Surg. 2015 Jul;26(5):1446-9. PMID: 26106996. [PubMed] [Read by QxMD] Interpersonal violence is a relatively infrequent cause of injury to the craniofacial skeleton in the pediatric population. The presentation of fractures as a result of different causes varies dramatically and can have a direct impact on management. The current study compares facial fractures in a pediatric population as a result of interpersonal violence with other mechanisms of injury. […]
Hoppe IC1, Kordahi AM, Paik AM, Lee ES, Granick MS. Examination of life-threatening injuries in 431 pediatric facial fractures at a level 1 trauma center. J Craniofac Surg. 2014 Sep;25(5):1825-8. PMID: 25203578. [PubMed] [Read by QxMD] Pediatric facial fractures represent a challenge in management due to the unique nature of the growing facial skeleton. Oftentimes, more conservative measures are favored to avoid rigid internal fixation and disruption of blood supply to the bone and soft tissues. In addition, the great force required to fracture bones of the facial skeleton often produces concomitant injuries that present a management priority. The purpose of this study was to e […]
Iso-Kungas P1, Törnwall J, Suominen AL, Lindqvist C, Thorén H. Dental injuries in pediatric patients with facial fractures are frequent and severe. J Oral Maxillofac Surg. 2012 Feb;70(2):396-400. PMID: 22260909. [PubMed] [Read by QxMD] This study was carried out to identify the occurrence, type, location, and severity of dental injuries (DIs), as well as predictors for DIs, in pediatric patients with facial fractures. […]
Imahara SD1, Hopper RA, Wang J, Rivara FP, Klein MB. Patterns and outcomes of pediatric facial fractures in the United States: a survey of the National Trauma Data Bank. J Am Coll Surg. 2008 Nov;207(5):710-6. PMID: 18954784. [PubMed] [Read by QxMD] Pediatric trauma involving the bones of the face is associated with severe injury and disability. Although much is known about the epidemiology of facial fractures in adults, little is known about national injury patterns and outcomes in children in the US. […]
Alcalá-Galiano A1, Arribas-García IJ, Martín-Pérez MA, Romance A, Montalvo-Moreno JJ, Juncos JM. Pediatric facial fractures: children are not just small adults. Radiographics. 2008 Mar-Apr;28(2):441-61; quiz 618. PMID: 18349450. [PubMed] [Read by QxMD] Radiologic imaging is essential for diagnosing pediatric facial fractures and selecting the optimal therapeutic approach. Trauma-induced maxillofacial injuries in children may affect functioning as well as esthetic appearance, and they must be diagnosed promptly and accurately and managed appropriately to avoid disturbances of future growth and development. However, these fractures may be difficult to detect on images, and they are frequently und […]

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It is often stated that “not all that Wheezes is Asthma,” but actually recalling what is on that Differential Diagnosis list is challenging. We have discussed several wheeze-related etiologies like Bronchiolitis, Heart Failure, Pneumonia, and Aspirated Foreign Bodies. Similarly, not all Stridor is Croup (ex, Recurrent Croup, RPA, and Tracheitis). Obviously, there are many conditions that need to be considered for these patients presenting with respiratory distress. Let’s take a moment to review one other condition that is often under-appreciated – Paradoxical Vocal Fold Movement:

Paradoxical Vocal Fold Movement: Basics
  • Paradoxical Vocal Fold Movement (PVFM) occurs when: [Matrka, 2014; Maturo, 2011]
    • the vocal fold(s) episodically, inappropriate constriction during respiration;
    • the vocal folds otherwise have normal movement outside these episodes;
    • there is no anatomic abnormality (ex, subglottic / tracheal stenosis)
  • Can be triggered by: [Ng, 2017; Matrka, 2014; Maturo, 2011]
    • Anything that irritates the vocal folds
      • Laryngopharyngeal reflux
      • Inhaled chemicals
      • Tobacco smoke
      • Allergic laryngitis
      • Viral illness
    • Exercise
      • Associated particularly with elite athletes.
      • Can be true cause of “exercised-induced” dyspnea.
    • Stress
      • Has been associated with psychiatric ailments, but does NOT need to be present. [Ng, 2017]
      • ~30% of patients found to have underlying psychiatric condition (which means ~70% are not). [Maturo, 2011]
    • Strong Odors / Perfumes
  • Several other terms have been used: [Ng, 2017; Matrka, 2014; Maturo, 2011]
    • Vocal Cord Dysfunction, Episodic laryngospasm, Irritable larynx syndrome, Fake asthma, and Munchausen stridor.
    • “Paradoxical Vocal Fold Movement” is preferred nomenclature now.
  • Likely UNDERdiagnosed. [Matrka, 2014; Maturo, 2011]
    • Presentation often mimics other common conditions, like asthma.
      • ~40% of patients misdiagnosed with Asthma.
    • Diagnosis requires laryngoscopy (direct or fiberscopic).
      • H+P will raise suspicion for it.
      • Ultrasound may prove to be helpful too. [Finnoff, 2018]
    • “Poorly controlled” asthma may, in fact, be PVFM.
    • Patients can have both PVFM and Asthma.
  • Undiagnosed PVFM has been associated with increased health care costs. [Matrka, 2014; Maturo, 2011]
    • Higher utilization of healthcare resources (ex, ED visits, hospitalizations)
    • Unnecessary procedures (ex, intubations, tracheostomies)
    • Average time between symptom onset and diagnosis is > 4 years. [Maturo, 2011]
PVFM: Presentation
  • Symptoms are non-specific and easily mimic other conditions (like Asthma). [Ng, 2017; Matrka, 2014; Maturo, 2011]
    • Dyspnea
    • Shortness of breath with exercise.
    • Throat/Neck Tightness
    • Stridor with exercise.
  • Symptoms often present abruptly. [Ng, 2017; Matrka, 2014; Maturo, 2011]
    • Associated with Exertion
    • Associated with Stressful / Emotional situation
    • May be raise concern for Acute Asphyxial Asthma.
  • Some distinguishing features: [Matrka, 2014]
    • Wheezing may be reported, but noisy inspiration more objectively noted. A Prominent Inspiratory component is often noted, although not required.
    • Absence of true end-expiratory wheeze is supportive of PVFM.
    • In elite athletes, high-intensity activity more likely to lead to symptoms rather than long, lower-intensity exercise.
    • Resolves more quickly with rest, compared to exercise-induced asthma.
    • Described choking sensation.
    • No improvement or alteration in symptoms with bronchodilator therapy.
    • Have had a history of normal Pulmonary Function Tests previously.
PVFM: Management
  • Don’t jump to conclusions!
    • Manage the respiratory distress as your training has taught you.
    • Patients with PVFM may have other concurrent conditions, like asthma or croup.
    • Heliox may also be helpful acutely. [Ng, 2017]
    • Nebulized lidocaine has also been found to be helpful acutely. [Ng, 2017]
  • Consider your Ddx.
    • Recurrent croup,” really? Should we recommend an outpatient ENT referral for further assessment of upper airway anomalies?
    • PVFM may be associated with psychiatric ailments, so consider the psycho-social implications.
  • Do a thorough exam!
    • Neurologic conditions may present similarly.
      • Dysphagia or Cranial Nerve deficits??
    • Cardiovascular entities may also present similarly.
    • Pay attention to the timing of the “wheeze” or stridor. Don’t forget to listen over the larynx.
  • Know the next steps. [Ng, 2017]
    • Main therapy of PVFM is speech therapy and psychiatric therapy.
    • Anti-anxiety medications may be helpful.
    • Some cases may require surgery.
Moral of the Morsel
  • Wheezing doesn’t Equate to Asthma! Keep your Ddx open while treating the patient.
  • Refer to your friendly ENT and/or Speech Pathologist for further evaluation if suspicious! You may not make the Dx, but your attention will place the patient on the right path!
References
Finnoff JT1, Orbelo DM2, Ekbom DC2. Can Ultrasound Identify Paradoxical Vocal Fold Movement? A Pilot Study. Clin J Sport Med. 2018 Aug 8. PMID: 30095506. [PubMed] [Read by QxMD] Vocal cord dysfunction (VCD) is characterized by paradoxical vocal fold movement (PVFM) during inspiration. The aim of this study was to determine whether ultrasound could accurately differentiate between normal and PVFM during respirations in a resting state. […]
Ng TT1. The forgotten cause of stridor in the emergency department. Open Access Emerg Med. 2017 Jan 16;9:19-22. PMID: 28144169. [PubMed] [Read by QxMD] Paradoxical Vocal Fold Movement Disorder is where the larynx exhibits paradoxical vocal cords closure during respiration, creating partial airway obstruction. Causes of vocal fold movement disorder are multifactorial, and patients describe tightness of throat, difficulty getting air in, have stridor, and do not respond to inhalers. We propose using transnasal laryngoscopy examination, which will show narrowing of vocal cords on inspiration, and T […]
Kramer S1, deSilva B1, Forrest LA1, Matrka L1. Does treatment of paradoxical vocal fold movement disorder decrease asthma medication use? Laryngoscope. 2017 Jul;127(7):1531-1537. PMID: 27861929. [PubMed] [Read by QxMD] To determine whether diagnosis and treatment of paradoxical vocal fold movement disorder (PVFMD) leads to decreased asthma medication use. Secondary objectives include determining initial rate of asthma medication use, characterizing symptom improvement, and correlating with pulmonary function testing (PFT). […]
Matrka L1. Paradoxic vocal fold movement disorder. Otolaryngol Clin North Am. 2014 Feb;47(1):135-46. PMID: 24286687. [PubMed] [Read by QxMD] Paradoxical Vocal Fold Movement Disorder (PVFMD) is a cause of dyspnea that can mimic or occur alongside asthma or other pulmonary disease. Treatment with Laryngeal Control Therapy is very effective once the entity is properly diagnosed and contributing comorbidities are managed appropriately. In understanding the etiology of PVFMD, focus has broadened beyond psychiatric factors alone to include the spectrum of laryngeal irritants (laryngopharyng […]
Franca MC1. Differential diagnosis in paradoxical vocal fold movement (PVFM): an interdisciplinary task. Int J Pediatr Otorhinolaryngol. 2014 Dec;78(12):2169-73. PMID: 25455524. [PubMed] [Read by QxMD] The objective of this study was to contribute to the discussion of differential diagnosis in paradoxical vocal fold movement (PVFM), a disorder frequently associated with episodes of breathing difficulty and stridor. Because of analogous respiratory symptoms, PVFM is often misdiagnosed as asthma. Additional evidence suggests the association of factors such as respiratory struggle during physical exertion, digestive reflux, and respiratory allergi […]
Koufman JA1, Block C. Differential diagnosis of paradoxical vocal fold movement. Am J Speech Lang Pathol. 2008 Nov;17(4):327-34. PMID: 18840701. [PubMed] [Read by QxMD] To present the differential diagnosis of paradoxical vocal fold movement (PVFM) and its distinguishing features. […]

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It is July and here in the Northern Hemisphere that means two things: newly minted doctors and kids finding ways to prove that Gravity works. We have covered numerous Gravity related items previously (ex, Trampoline Injuries, Trauma Pitfalls, Concussion, C-Spine Injury, Horse-related Injuries, Abdominal Trauma). Certainly, broken bones are quite prominently encountered during the summer (ex, Wrist Fracture, UE fractures, Hand Fractures, Foot Fractures), but there is one unique aspect of pediatric fractures that should not be overlooked. Basics are important… so let us quickly review Salter-Harris Classifications:

Salter-Harris Classification
  • Fractures involving the growth plates (epiphyseal plate / physis) are common in children.
  • Having a system to describe them that relates to the anatomy as well as the prognosis is important.
    • There are numerous classifications systems in existence…
    • The most commonly used was described in 1963 by Robert B. Salter and W. Robert Harris. [Cepela, 2016]
  • The Physis is the weakest part! [Cepela, 2016]
    • Immature bones have different fracture patterns from mature ones.
    • The ligaments and tendons may actually be stronger than the physis (see Ankle Injury).
    • Physis can be subdivided into four different zones anatomically.
      • Zone 1 – “resting zone” – adjacent to epiphysis, mostly inactive
      • Zone 2 – “proliferative zone” – active chondrocytes
      • Zone 3 – “Hypertrophic zone” – large chondrocytes – contains the zone of provisional calcification, the weakest area.
      • Zone 4 – “Zone of calcification” – where calcified cartilage begins to remodel into bone.
    • The transition point between calcified and non-calcified extracellular matrix within the physis is the weakest portion and susceptible to injury.
  • Physeal Injuries have the potential for complications: [Cepela, 2016]
    • Growth arrest
    • Deformity
  • Not all injuries have the same risk for complications (and is why a classification system is helpful).
Salter-Harris Classification
  • Salter-Harris Classification:
    • Focused on injuries at the pressure epiphyses [Cepela, 2016]
      • There are two types of epiphyses – pressure and traction
      • Pressure type provide longitudinal growth and bear weight.
      • Traction type provide appositional growth at origin/insertion of muscles and do not bear weight.
    • Describes 5 different types (although others have also been described)
  • TYPE I [Cepela, 2016]
    • Extends through the growth plate
    • Separates the epiphysis from the metaphysis.
    • More common in younger children who have a thicker physis.
  • TYPE II [Cepela, 2016]
    • The most common type of epiphyseal fracture (~74%).
    • Fracture extends through the physis and exists through the metaphysis.
    • Is not intra-articular.
    • The broken off piece of metaphysis = Thurston-Holland fragment.
  • TYPE III [Cepela, 2016]
    • Fracture extends through the physis and exists the epiphysis.
    • Is INTRA-ARTICULAR.
    • May lead to post-traumatic arthritis and growth arrest.
  • TYPE IV [Cepela, 2016]
    • Fracture crosses the physis and extends through the metaphysis and epiphysis.
    • Is INTRA-ARTICULAR.
    • Has longitudinal INSTABILITY.
    • May lead to complete physical arrest and symmetric growth or growth deformity (if not reduced longitudinally correctly).
  • TYPE V
    • A crush injury of the physis due to compressive forces.
    • May also be a stress (overuse) type injury seen with repetitive loading of force (ex, gymnast).
    • Rare.
Moral of the Morsel
  • Anatomy Matters. Kids are not aliens… they are just little humans with different anatomy and physiology that must be taken into account.
  • Ankle Sprain? Are you Sure? Remember, the weakest part isn’t the ligament… it is the physis.
References
Cepela DJ1, Tartaglione JP2, Dooley TP2, Patel PN3. Classifications In Brief: Salter-Harris Classification of Pediatric Physeal Fractures. Clin Orthop Relat Res. 2016 Nov;474(11):2531-2537. PMID: 27206505. [PubMed] [Read by QxMD]

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It may not be apparent, but the Ped EM Morsels have been a weekly publication since 2010 (actually really since 2008). They have been published every week since… except for when ugly Spammers crash the servers. This is actually the 457th Morsel posted. All of them have been inspired by actual patient encounters and real clinical questions. Many of my fantastic colleagues and residents at Carolinas Medical Center have helped guide me toward the important topics and questions. Now… this week… I call upon the power of the FOAM community. Take a moment and tell me what CLINICAL Question you would like me to write the next Morsel about! Submit your CLINICAL Question via the Comment function on the website below… or by emailing the question to pedemmorselsfox@gmail.com. Let’s see what the next ~450 Morsels bring!

THANK YOU FOR YOUR CONTINUED SUPPORT! I greatly appreciate it!

– sean

The post What’s Your Clinical Question? appeared first on Pediatric EM Morsels.

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School is out and Summer is in full swing (at least up here in the Northern Hemisphere) and that means … more pediatric trauma (sadly)! Pediatric Trauma can be very challenging to manage for numerous reasons (many that we have already touched upon within the Morsels). The child’s different anatomy and physiology and their changes that occur relative the patient’s age make the can obscure the potential hazards. Recently, a nice review was published [Acker, 2019] that reminds us to remain vigilant for some of these Pediatric Trauma Pitfalls:

Pediatric Trauma: Some Differences
  • Trauma is the leading cause of Morbidity and Mortality (M&M) in children (as well as young adults)!
  • While not aliens, children do have different anatomy and physiology that needs to be accounted for, like:
    1. Higher Metabolic Rate + Smaller Functional Residual Capacity = Desaturations occur RAPIDLY!
    2. Compliance Chest Walls = Poor protection to underlying structures (ie, more likely to have pulmonary contusion and solid organ injury than rib fractures)
    3. Thin Abdominal Wall Musculature = Poor protection to underlying organs which can be injured even without objective signs of abdominal trauma.
    4. Very Flexible Tissues = which can be advantageous (very low risk for aortic traumatic injury), but airways can be easily compressed.
    5. Relatively Large Head / Occiput = Hyperflexion of the young child’s neck when supine which can lead to suboptimal airway alignment.
Pediatric Trauma Pitfalls: Remain Vigilant
  • Aside from the above considerations, other potential Errors / Pitfalls to be considered while evaluating the pediatric trauma patient include: [Acker, 2019]
  • Under-appreciating Hemodynamic Instability
    • Shock can be challenging to recognize in a child.
    • Children compensate very well! May not see hypotension until loss of >30% blood volume!
    • Blood pressure may not be your best indicator! Look at Cap Refill!
    • Use the Shock Index Age Adjusted also.
    • Don’t delay getting access… if it is denied… use an Intraosseous line!
    • If blood loss is significant consider Damage Control Resuscitation!
  • Overlooking Blunt Cerebrovascular Injury
    • Blunt injury to the carotid or vertebral arteries is rare, but if present can lead to significant M&M.
    • Often present in delayed fashion (10-72 hours) after initial injury.
    • The risk factors for cerebrovascular injury in children have yet to be defined clearly… but one study found the following to be associated with it:
      • GCS </= 8
      • ISS = 16
      • Presence of cerebral hemorrhage
      • Infarct on head imaging
      • Cervical spine fracture
      • Basilar skull fracture
    • Clavicular fractures have also been associated with it.
  • Overlooking Small Bowel / Mesentery Injury
    • Less protective rib cage and abdominal musculature place the intra-abdominal organs at risk.
    • Hollow viscus can be injured via direct blows (ie, handlebar) or by compression from seat belt against spinal column.
    • Hollow viscus injuries may present in a delayed fashion.
    • Respect the presence of a Seat Belt Sign!
    • Serial exams are important, as CT may not show the injury.
  • Under-appreciating the Potential for NAT
    • NAT can lead to very dramatic presentations, but can also be subtle – look for sentinel bruising.
    • Head Injury is the most common and most lethal injury due to NAT.
    • ANY SUSPICION (not actual diagnosis) needs to be reported to the authorities!
Moral of the Morsel
  • Pediatric Patients are NOT Aliens! They do, however, have different anatomy and physiology that must be considered!
  • Pediatric Trauma patients can be even more challenging than adults to evaluate. Remain vigilant and be aware of the presence of the pitfalls!
References
Acker SN1, Kulungowski AM2. Error traps and culture of safety in pediatric trauma. Semin Pediatr Surg. 2019 Jun;28(3):183-188. PMID: 31171155. [PubMed] [Read by QxMD] Trauma is the leading cause of morbidity and mortality in the pediatric population. Due to a variety of factors, many pediatric trauma patients are initially evaluated and stabilized at adult hospitals that lack pediatric specific emergency medicine and surgical expertise. While similar to adult patients, the initial evaluation and resuscitation of pediatric patients does differ. Many of these key differences contribute to missed injury and susce […]

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Pediatric ECGs are useful screening tools that we like to use for cases of Syncope or Chest Pain. While we may be actively looking for signs of Prolonged QTc, Brugada Sign, WPW, or Pulmonary Embolism, what we may find, instead, is huge voltages that seem to dominate the entire sheet. We’ve discussed the differences that must be accounted for when evaluating the Pediatric ECG previously. Let us take a moment to reiterate the issues to contemplate when considering either Left or Right Ventricular Hypertrophy:

Pediatric ECG: Large Voltages?
  • The pediatric patient’s chest wall is typically thinner (although that is not always the case) than the adult’s.
    • The closer proximity of the ECG leads to the heart muscle can exaggerate the voltages.
    • V2 through V5 are the most likely to be artificially exaggerated.
  • Before becoming “excited” about the “large voltages” seen in the precordial leads, consider:
    • The ECG interpretation will often “over-report” left or right ventricular hypertrophy (don’t read the interpretation!).
    • Make sure the standardization marks are set to Full Standard (2 big boxes).
    • ECG does NOT diagnose LVH or RVH… LVH and RVH are anatomic conditions and ECGs do not determine anatomy.
  • There are several “rules” that help evaluate for abnormally large voltages on the pediatric ECG.
    • Most are complicated and less practical.
    • One practical approach is: [Evans, 2010]
      • Abnormal Left Ventricular Large Voltage (“LVH”)
        • Use only V6 (the left most precordial lead)
        • If R wave of V6 intersects with baseline of V5, then that is abnormal.
      • Abnormal Right Ventricular Large Voltage (“RVH”)
        • Use only V1 (the right most precordial lead)
        • Upright T wave in V1?
          • During 1st week of life, T wave can be upright in V1.
          • After 1st week of life, upright T wave in V1 is abnormal in children until adolescence.
        • If RSR’ is present and if R’ is taller than R wave, then this is abnormal.
        • A pure R wave in V1 in a child > 6 months of age is abnormal.
Hypertrophy Ddx (abridged)
  • Right Ventricular “Hypertrophy”
    • Diagnosis should be made cautiously in children < 6 months (due to age dependent factors). [O’Connor, 2008]
    • After 6 months, consider:
  • Left Ventricular “Hypertrophy”
    • Always unusual in a newborn [O’Connor, 2008]
      • Aortic Stenosis
      • Coarctation
      • Ventricular Septal Defect (VSD)
      • Patent Ductus Arteriosus (PDA)
    • In older children may be a sign of:
      • Hypertrophic Obstructive Cardiomyopathy. [O’Connor, 2008]
      • Or delayed Dx of:
        • Aortic Stenosis
          Coarctation
          Ventricular Septal Defect (VSD)
          Patent Ductus Arteriosus (PDA)
Moral of the Morsel
  • Small chest walls will exaggerate precordial voltages. Know what is normal.
  • Know the Evans’ Rules! While there are other “rules” for RVH and LVH, the ones described by Evans et al. are very practical. 
  • The ECG generates a DDx not a Dx. Use the ECG as a way to help generate and sort through your Ddx.
References
Evans WN1, Acherman RJ, Mayman GA, Rollins RC, Kip KT. Simplified pediatric electrocardiogram interpretation. Clin Pediatr (Phila). 2010 Apr;49(4):363-72. PMID: 20118092. [PubMed] [Read by QxMD] We describe a simplified method for interpreting a pediatric electrocardiogram (EKG). The method uses 4 steps and requires only a few memorized rules, and it can aid health care providers who do not have immediate access to pediatric cardiology services. Most pediatric EKGs are normal. However, both abnormal and normal EKGs should be sent to a pediatric cardiologist for later, confirmatory interpretation. […]
O’Connor M1, McDaniel N, Brady WJ. The pediatric electrocardiogram part III: Congenital heart disease and other cardiac syndromes. Am J Emerg Med. 2008 May;26(4):497-503. PMID: 18410822. [PubMed] [Read by QxMD] Approximately 1% of newborns are affected by congenital heart disease (CHD), and although many lesions of CHD have trivial hemodynamic and clinical implications, some clinically significant lesions are asymptomatic in the immediate newborn period and may present after discharge from the well baby nursery. Because of this, CHD should be considered in the differential diagnosis of any ill-appearing newborn, regardless of the presence of cyanosis. I […]
O’Connor M1, McDaniel N, Brady WJ. The pediatric electrocardiogram part II: Dysrhythmias. Am J Emerg Med. 2008 Mar;26(3):348-58. PMID: 18358948. [PubMed] [Read by QxMD] The following article in this series will describe common arrhythmias seen in the pediatric population. Their definitions and clinical presentations along with electrocardiogram (ECG) examples will be presented. In addition, ECG changes seen in acute toxic ingestions commonly seen in children will be described, even if such ingestions do not produce arrhythmias per se. Disturbances of rhythm seen frequently in patients with unrepaired and correct […]
O’Connor M1, McDaniel N, Brady WJ. The pediatric electrocardiogram. Part I: Age-related interpretation. Am J Emerg Med. 2008 Feb;26(2):221-8. PMID: 18272106. [PubMed] [Read by QxMD] Emergency physicians attending to pediatric patients in acute care settings use electrocardiograms (ECGs) for a variety of reasons, including syncope, chest pain, ingestion, suspected dysrhythmias, and as part of the initial evaluation of suspected congenital heart disease. Thus, it is important for emergency and acute care providers to be familiar with the normal pediatric ECG in addition to common ECG abnormalities seen in the pediatric populat […]

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I was always taught to have a very healthy respect for infections of the Hands, Feet, or Face. Certainly, the infection itself can be problematic (tenosynovitis, plantar puncture, sinusitis, otitis media), but those particular areas have lots of very delicate and important structures in extremely close proximity… and that combination can lead to significant complications. Fortunately, the potential complications are rarely encountered. Unfortunately, their rarity may make our consideration of them challenging (ex, Gradenigo’s Syndrome). Let us maintain our reasonable vigilance and discuss another important complication – Cavernous Sinus Thrombosis:

Cavernous Sinus
  • The anatomy of the Cavernous Sinus is important to consider.
    • It is an irregular shaped space lined with endothelium.
    • It is on either side of the sella turcica.
    • It is lateral and superior to the sphenoid sinus.
    • It is immediately posterior to the optic chiasm.
  • Venous drainage is from the “Danger Triangle!” [Smith, 2015; Varshney, 2015]
    • Region from the corners of the mouth to the bridge of the nose and inclusive of the nose and maxilla.
    • Venous drainage from:
      • Superior and Inferior Ophthalmic Veins
      • Sphenoid and Middle Cerebral Veins
      • Facial Vein
    • Also drainage from frontal sinuses.
    • The connecting veins to and from the Cavernous Sinus lack valves so blood can flow in either direction… and thrombosis can migrate in both directions. [Varshney, 2015]
Cavernous Sinus Thrombosis
  • Cavernous Sinus Thrombosis is rare, but life-threatening. [Smith, 2015; Frank, 2015]
    • Frequency has been reduced since high utilization of antibiotics.
    • Mortality has been also reduced, but still exists and morbidity can be significant.
    • Usually a late complication of an infection of the central face. [Varshney, 2015]
  • Potential complications of Sinus Thrombosis include:
    • Injury to any of the structures contained within the Cavernous Sinus: [Smith, 2015]
      • CNs III, IV, V1, V2, VI
      • Internal carotid artery
    • Involvement in contiguous / adjacent structures: [Smith, 2015]
  • Prompt recognition is key to limiting complications! [Smith, 2015; Frank, 2015]
    • “Classic Presentation” = severe illness with high, fluctuating fevers in the setting of recent mid-face infection. [Varshney, 2015]
    • Common symptoms:
      • Severe Headache
      • Periorbital Swelling
      • Ptosis
      • Inability to Move Eyes
      • Pain / Numbness around midface and eyes
      • Vision Changes / Double Vision / Loss of Vision [Frank, 2015]
      • Seizures
      • High Fevers
Cavernous Sinus Thrombosis: Management
  • There is no current consensus guidelines for management of Cavernous Sinus Thrombosis. [Smith, 2015]
  • Imaging: [Smith, 2015; Frank, 2015]
    • Contrast-enhanced CT
      • Useful, but has radiation concerns.
    • Contrast-enhanced MRI [Rodriguez-Homs, 2019; Frank, 2015]
      • More difficult to come by in the ED.
      • Not MRV. MRV (venogram) has been found to miss some cases.
      • The slow turbulent flow may allow thrombus to be missed on MRV.
  • Therapy typically includes: [Smith, 2015; Varshney, 2015; Frank, 2015]
    • Antimicrobials
      • Empiric antibiotics (ex, Cephalosporin AND Metronidazole AND Vancomycin) should be initiated early.
      • Typical bacterial infections include:
        • Staph
        • Strep
        • Anaerobic bugs
      • Fungal infections (ex, Aspergillus, Rhizopus) have been shown to be important considerations in:
        • Immunocompromised patients
        • Diabetic patients
        • Patients on chronic steroids
    • Anticoagulation
    • Surgery
      • Functional Endoscopic Sinus Surgery has been advocated for, but not often required emergently.
      • Consultation with ENT early is important to help coordinate care for those who are not improving on antibiotics.
Moral of the Morsel
  • Remain Vigilant! It may be rare… but if there is a mid-face infection and High Fevers, Periorbital Edema, and/or Cranial Nerve abnormalities… think of Cavernous Sinus Thrombosis.
  • Abx STAT! Get the antimicrobial coverage started… and consider antifungals for at risk patients.
  • Consult ENT… but don’t expect emergent surgery.
References
Rodriguez-Homs LG1, Goerlitz-Jessen M1, Das SU1. A 17-Year-Old Girl With Unilateral Headache and Double Vision. J Investig Med High Impact Case Rep. 2019 Jan-Dec;7:2324709619838309. PMID: 31010318. [PubMed] [Read by QxMD] Tolosa-Hunt syndrome is characterized by a painful ophthalmoplegia secondary to a granulomatous inflammation in or adjacent to the cavernous sinus. Magnetic resonance imaging will show enhancement of the cavernous sinus and/or the orbital apex. Although this syndrome is extremely rare in children, it should be a diagnostic consideration in patients presenting with painful ophthalmoplegia with variable involvement of cranial nerves II to VI. The d […]
Rebelo J1, Nayan S2, Choong K3, Fulford M4, Chan A5, Sommer DD6. To anticoagulate? Controversy in the management of thrombotic complications of head & neck infections. Int J Pediatr Otorhinolaryngol. 2016 Sep;88:129-35. PMID: 27497400. [PubMed] [Read by QxMD] To review the thrombotic complications of head and neck infections, including Lemierre’s syndrome, and their management. […]
Smith DM1, Vossough A2, Vorona GA2, Beslow LA2, Ichord RN2, Licht DJ2. Pediatric cavernous sinus thrombosis: A case series and review of the literature. Neurology. 2015 Sep 1;85(9):763-9. PMID: 26231260. [PubMed] [Read by QxMD] To describe clinical characteristics, imaging findings, morbidity, and mortality in a single-center cohort of 12 pediatric cavernous sinus thrombosis cases and to review all cases available in recent English literature. […]
Varshney S1, Malhotra M1, Gupta P1, Gairola P1, Kaur N1. Cavernous sinus thrombosis of nasal origin in children. Indian J Otolaryngol Head Neck Surg. 2015 Mar;67(1):100-5. PMID: 25621244. [PubMed] [Read by QxMD] Cavernous sinus thrombosis is a rare presentation. Early diagnosis and aggressive treatment are required to prevent morbidity and mortality. Nasal infections can give rise to serious intracranial complications. Presented here is a case series of cavernous sinus thrombosis of nasal septic origin. The purpose of this article is to report our experience in pediatric patients with this illness to ascertain a clinical course and outcomes for further c […]
Frank GS1, Smith JM1, Davies BW2, Mirsky DM3, Hink EM1, Durairaj VD4. Ophthalmic manifestations and outcomes after cavernous sinus thrombosis in children. J AAPOS. 2015 Aug;19(4):358-62. PMID: 26239205. [PubMed] [Read by QxMD] To review the causes, treatment, and outcomes of cavernous sinus thrombosis (CST) in children. […]
Reid JR1. Complications of pediatric paranasal sinusitis. Pediatr Radiol. 2004 Dec;34(12):933-42. PMID: 15278322. [PubMed] [Read by QxMD] Acute paranasal sinus infection in children is often diagnosed clinically without the need for radiographic confirmation. Most cases have a favorable outcome following appropriate antibiotic therapy. A small percentage of cases where symptoms and signs are persistent or severe will require emergent imaging to rule out complications related to local spread of disease intraorbitally or intracranially. A strong index of suspicion is required in such […]
Cannon ML1, Antonio BL, McCloskey JJ, Hines MH, Tobin JR, Shetty AK. Cavernous sinus thrombosis complicating sinusitis. Pediatr Crit Care Med. 2004 Jan;5(1):86-8. PMID: 14697115. [PubMed] [Read by QxMD] Septic cavernous sinus thrombosis is a rare complication of paranasal sinusitis. […]

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In Charlotte, it has been unseasonably HOT and many of us have been considering escaping to the mountains. Maybe not exactly the way these people have, but at least something to help our families cool off. This lead Dr. Cathy Wares (CMC Assistant Program Director Extraordinaire) to ponder just how children are affected by that High Altitude environment. Great question… let us take a minute to explore High Altitude Illness in Children:

High Altitude Illness: Pediatric Considerations
  • Involvement of children in high altitude environments has been increasing. [Heggie, 2018; Garlick, 2017; Joy, 2015; Moraga, 2002]
    • Alpine skiing / snowboarding and extreme sports are notable.
    • Vacations/Visitation to high altitude areas.
      • Denver, Colorado is ~5,500 feet above sea level.
      • Breckenridge, Colorado is ~10,000 ft above sea level.
      • Rocky Mountains are ~10,000 ft above sea level.
  • Hypobaric Hypoxia leads to the physiologic stressors associated with High Altitude Illnesses (HAI).
    • Increasing altitudes -> lower barometric pressure -> lower partial pressure of oxygen.
    • Decreased partial pressure of oxygen reduces the pressure gradient -> reduced force to drive oxygen into tissues => Hypobaric Hypoxia
    • Effects of Hypobaric Hypoxia can be seen first at altitudes of 5,000 feet.
  • Children are in the group of people who are at greatest risk for environmental illness or injury.
    • The younger the child, the greater the risk. [Heggie, 2018]
    • The longer the expedition, the greater the risk of illness/injury to children present. [Heggie, 2018]
    • Other Risk Factors: [Garlick, 2017; Joy, 2015]
High Altitude Illness: Critical Syndromes
  • ACUTE MOUNTAIN SICKNESS (AMS)
    • The most common HAI in children and adults. [Garlick, 2017]
    • Headache is the principle feature.
    • Diagnosis = Headache PLUS:
      • Insomnia, dizziness, fatigue, nausea/vomiting, or anorexia
      • In a patient who recently traveled to that altitude (usually >8,000 feet) … so not acclimatized yet.
      • In younger, non-verbal children, AMS may present with increased fussiness, decreased interaction/playfulness, decreased appetite, sleep disturbances. [Joy, 2015]
    • Prevention:
      • Best prevention is gradual ascent.
      • Acetazolamide: [Garlick, 2017]
        • Used off label in children.
        • 2.5 mg/kg/dose BID (max of 125 mg BID)
        • Has side effects (ex, metal taste in mouth, paresthesias) so often not used prophylactically.
    • Treatment:
      • Halt further ascent! May need to descend if symptoms are severe or not improving.
      • NSAIDs and Antiemetics. [Joy, 2015]
      • Acetazolamide: [Garlick, 2017; Joy, 2015]
        • 2.5 mg/kg/dose BID (max of 125 mg BID)
        • Usually not as effective as it is for prophylaxis.
      • Dexamethasone: [Garlick, 2017]
        • Used if symptoms are severe (along with descent).
        • 0.15 mg/kg/dose q 6 hrs.
  • HIGH ALTITUDE PULMONARY EDEMA (HAPE)
    • Non-cardiogenic pulmonary edema caused by hypobaric hypoxia.
    • Presents with: [Garlick, 2017; Joy, 2015]
      • Dyspnea (particularly at rest), exercise intolerance, cough
      • Hemoptysis
      • Tachycardia, tachypnea, rales, cyanosis
    • Highest associated mortality rate of all of the HAIs.
    • Risk Factors for HAPE: [Garlick, 2017]
      • Children who live at higher altitude, who descend, then return to higher altitude (“re-entrant pulmonary edema“). [Joy, 2015; Polli, 2015]
      • Genetically predisposed
      • Elevations > 9,842 feet (3,000 meters)
      • More rapid ascent
      • Recent upper respiratory tract infection
    • Prevention:
      • Gradual ascent is best way to avoid HAPE.
      • Medication use (Diuretics and/or Nifedipine) have been used, but not studied and would be used off label. [Garlick, 2017]
    • Treatment:
      • Immediate descent… but without exertion (so carried down to lower altitude). [Garlick, 2017]
      • Supplemental Oxygen!
      • Medications have not been found to hasten recovery…
        • Used when oxygen therapy isn’t available. [Joy, 2015]
        • Nifedipine 30 mg Sustained Release q 12 hours.
        • Sildenafil 0.5 mg/kg/dose q 4-8 hours (max = 50 mg/dose)
  • HIGH ALTITUDE CEREBRAL EDEMA (HACE)
    • Distinct from Acute Mountain Sickness by presence of neurologic impairment: [Garlick, 2017]
      • Ataxia, Confusion, Altered Mental Status
      • Can follow Acute Mountain Sickness though.
    • Very rare in children
      • Likely related to being rare in adults and…
      • Primarily occurring at elevations > 13,123 feet (4,000 meters).
    • Treatment:
      • Immediate descent.
      • Supplemental Oxygen.
      • Dexamethasone: [Garlick, 2017]
        • 0.15 mg/kg/dose q 6 hrs.
Moral of the Morsel
  • Kids travel to the highest of heights! Achievement is great… but High Altitude Illness is not!
  • The Tortoise will beat the Hare! Ascending slowly is the key to prevention!
  • Know who is at higher risk! Chronic lung conditions are particularly problematic!
  • Going Home can make some sick! Re-Entrant Pulmonary Edema can be seen in children more than in adults.
References
Heggie TW1,2, Küpper T3. Pediatric and adolescent injury in wilderness and extreme environments. Res Sports Med. 2018;26(sup1):186-198. PMID: 30431353. [PubMed] [Read by QxMD] The participation of children and adolescents in wilderness and extreme environment sports is increasing. Engaging in these activities is not without risk of injury, illness, or death. To date, there is limited research investigating pediatric and adolescent injuries in wilderness and extreme environments. With the intent of creating awareness within the sports medicine field, this review begins by examining the growth in popularity of outdoor sp […]
Ryan S1,2, Dudley N3,2, Green M2, Pruitt C3,2, Jackman G4. Altered Mental Status at High Altitude. Pediatrics. 2018 Aug;142(2). PMID: 29976571. [PubMed] [Read by QxMD] Intrathecal baclofen pumps are commonly used in pediatric patients with spastic cerebral palsy. Baclofen binds to γ-aminobutyric acid receptors to inhibit both monosynaptic and polysynaptic reflexes at the spinal cord level. The blockade stops the release of excitatory transmitters and thereby decreases muscle contraction. It is commonly used for lower limb spasticity and has been shown to improve postural ability and functional status. The US F […]
Garlick V1, O’Connor A, Shubkin CD. High-altitude illness in the pediatric population: a review of the literature on prevention and treatment. Curr Opin Pediatr. 2017 Aug;29(4):503-509. PMID: 28582330. [PubMed] [Read by QxMD] Increasing numbers of children are now traveling to high-altitude destinations, and pediatricians often see these children prior to and immediately following their travels. Thus, pediatricians have the opportunity to provide guidance for the prevention of altitude illness and must treat high-altitude illness (HAI) in some circumstances. This review will examine guidelines for prevention and management of HAI in the pediatric population. […]
Joy E1, Van Baak K2, Dec KL3, Semakula B4, Cardin AD5, Lemery J6, Wortley GC7, Yaron M6, Madden C8. Wilderness Preparticipation Evaluation and Considerations for Special Populations. Wilderness Environ Med. 2015 Dec;26(4 Suppl):S76-91. PMID: 26617382. [PubMed] [Read by QxMD] Children, older adults, disabled and special needs athletes, and female athletes who participate in outdoor and wilderness sports and activities each face unique risks. For children and adolescents traveling to high altitude, the preparticipation physical evaluation should focus on risk assessment, prevention strategies, early recognition of altitude-related symptoms, management plans, and appropriate follow-up. As the risk and prevalence of chro […]
Polli JB1, Polli I2. Traveling with children: beyond car seat safety. J Pediatr (Rio J). 2015 Nov-Dec;91(6):515-22. PMID: 26232504. [PubMed] [Read by QxMD] To spread knowledge and instigate the health professional to give advice on childcare during travels and on child transport safety. […]
Moraga FA1, Osorio JD, Vargas ME. Acute mountain sickness in tourists with children at Lake Chungará (4400 m) in northern Chile. Wilderness Environ Med. 2002 Spring;13(1):31-5. PMID: 11929059. [PubMed] [Read by QxMD] To evaluate the presence of acute mountain sickness (AMS) and cardiorespiratory responses in adult and pediatric tourists exposed to high altitude (Putre and Chungará). […]

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A common theme amongst the Ped EM Morsels is remaining vigilant while maintaining a reasonable approach to the care of children. Many devastating conditions can be quite subtle in their initial presentation. Last week, a prior PEM graduate from Carolinas Medical Center, Dr. Simone Lawson joined me to chat about a potentially devastating condition that can easily be, and unfortunately is, often missed at first presentation: Child Abuse. While discussing this critically important topic on EMGuideWire’s Core Concepts (take a listen and consider subscribing – it’s free!) with our Child Protection expert, Dr. Pat Morgan, a useful tool was brought up to help us all not miss the subtle presentation of child abuse. I wanted to reiterate it here. Let’s take a minute to remember the importance of Sentinel Bruising and Abusive Injuries in Children:

Bruising in the Peds ED
  • Bruising is commonly seen in the Pediatric ED. [Pierce, 2016]
    • Infrequently is it related to a medical condition (ex, Hemophilia, ITP).
    • Most often it is related to traumatic complaints (Gravity works!).
    • Non-accidental Trauma… is Trauma… but can be overlooked easily.
  • Bruising may be the “sentinel” sign of non-accidental trauma in a child. [Pierce, 2017; Pierce, 2017; Pierce, 2009]
    • It is known to be under-appreciated in those children who later are found to be severely injured or killed.
    • 28-64% of children who sustain severe physical abuse were found to have had a prior “sentinels” bruise. [Pierce, 2017; Pierce, 2017]
Bruising: Looking for Red Flags

If bruises occur commonly, are often due to explainable accidents, and we often overlook them as they don’t require specific therapy, BUT they can also be the first clue indicating physical abuse is occurring, how can we reasonable remain vigilant?

Look for well known Red Flags!

  • Bruising characteristics that are concerning for abuse: [Pierce, 2016; Pierce, 2010]
    • Number of Bruises
      • More than 3 bruises from one event are uncommonly due to accidents (unless from falls down stairs or MVCs)
      • Having 5+ bruises is very concerning.
    • Location of Bruises
      • Posterior surface (Torso, buttocks, posterior legs)
      • Front AND Back of the body from reported single event is concerning!
      • Ears
      • Neck
      • Hands
      • Chest
      • Genitals
    • Type of Bruises
      • Petechial bruising
      • Bruises with Patterns
        • Linear
        • Appearance similar to a known object
  • TEN – 4 FACES P [Pierce, 2016; Pierce, 2010]
    • In children less than 4 years of age, bruises on these areas raise concern for physical abuse:
      • Trunk
      • Ears
      • Neck
    • ANY BRUISE on a child less than 4 months of age is concerning!
      • It’s always good to recall your Developmental Milestones!
      • “Kids that don’t cruise rarely bruise.” [Pierce, 2009]
      • Infant homicide rates are highest in the first 4 months of life.
    • Additionally, bruises on these areas should also raise concerns:
      • Frenulum (tear or bruising)
      • Auricular area
      • Cheek
      • Eyes
      • Sclera
    • Patterned bruising is always concerning!
  • Ask more questions:
    • If a possible “sentinel” bruise is discovered, ask more questions.
    • If a plausible cause of the bruising cannot be discerned, then non-accidental trauma should be high on the list of concerns.
    • Having a confirmed accident in a public setting that can be attributed to the bruise can be reassuring. [Pierce, 2010]
    • All you need is a concern for abuse (you don’t need definitive evidence) to report this concern to protective services and resources.

Moral of the Morsel
  • Put them in Gowns (or at least look at the skin)! Every encounter is an opportunity to ensure each child is safe and well cared for.
  • Remain vigilant! Look for Red Flags of abuse (TEN-4 FACES P).
  • Ask more questions. Does the reported event make sense to have caused bruises on the front AND back of the Torso??
References
Lorenz DJ1, Pierce MC2, Kaczor K3, Berger RP4, Bertocci G5, Herman BE6, Herr S7, Hymel KP8, Jenny C9, Leventhal JM10, Sheehan K2, Zuckerbraun N4. Classifying Injuries in Young Children as Abusive or Accidental: Reliability and Accuracy of an Expert Panel Approach. J Pediatr. 2018 Jul;198:144-150. PMID: 29550228. [PubMed] [Read by QxMD] To assess interrater reliability and accuracy of an expert panel in classifying injuries of patients as abusive or accidental based on comprehensive case information. […]
Pierce MC1, Kaczor K2, Acker D3, Webb T4, Brenzel A5, Lorenz DJ6, Young A7, Thompson R8. History, injury, and psychosocial risk factor commonalities among cases of fatal and near-fatal physical child abuse. Child Abuse Negl. 2017 Jul;69:263-277. PMID: 28500923. [PubMed] [Read by QxMD] Failure to recognize child maltreatment results in chronic exposure to high-risk environments where re-injury or death may occur. We analyzed a series (n=20) of fatal (n=10) and near-fatal (n=10) physical child abuse cases from the Commonwealth of Kentucky to identify commonalities and determine whether indicators of maltreatment were present prior to the child’s fatal or near-fatal event. We conducted retrospective state record reviews involving […]
Pierce MC1, Magana JN2, Kaczor K3, Lorenz DJ4, Meyers G5, Bennett BL5, Kanegaye JT2. The Prevalence of Bruising Among Infants in Pediatric Emergency Departments. Ann Emerg Med. 2016 Jan;67(1):1-8. PMID: 26233923. [PubMed] [Read by QxMD] Bruising can indicate abuse for infants. Bruise prevalence among infants in the pediatric emergency department (ED) setting is unknown. Our objective is to determine prevalence of bruising, associated chief complaints, and frequency of abuse evaluations in previously healthy infants presenting to pediatric EDs. […]
Pierce MC1, Kaczor K, Aldridge S, O’Flynn J, Lorenz DJ. Bruising characteristics discriminating physical child abuse from accidental trauma. Pediatrics. 2010 Jan;125(1):67-74. PMID: 19969620. [PubMed] [Read by QxMD] Our objective was to conduct a pilot study to identify discriminating bruising characteristics and to model those findings into a decision tool for screening children at high risk for abuse. […]
Pierce MC1, Smith S, Kaczor K. Bruising in infants: those with a bruise may be abused. Pediatr Emerg Care. 2009 Dec;25(12):845-7. PMID: 20016354. [PubMed] [Read by QxMD] Bruising in the young infant is rare, and if present, this may be a manifestation of physical child abuse. Early signs of abuse, such as bruising, are often overlooked or their significance goes unrecognized resulting in poor patient outcomes. In such cases, the opportunity to intervene and potentially prevent repeat injury is lost, and the child is placed back in harm’s way. This brief report presents 3 cases of nonmobile infants who presented t […]

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Keeping children comfortable benefits everyone! Patients have less pain and psychological trauma. Their families think you are amazing and… your procedure is easier to do when not also performing professional wrestling maneuvers. Honestly, a successful procedural sedation is one of the best things to do in the ED. It satisfies everyone… which makes for some good job satisfaction while you are driving home. On the other hand… a less than successful sedation is… well, not satisfying at all. Recently, my stellar Pediatric EM Fellows and I were discussing sedation practices. We spoke of Ketamine for pain and sedation and how it can be given via the nostril route! Nitrous was also discussed and how it is almost the perfect tool for the job — yet, many are still unfamiliar with it. Then we discussed the nearly omnipresent topic of “Ketofol.” Even this old dog can learn a new trick I suppose… but do I need to? Let’s look briefly at Ketamine and Propofol (Ketofol) for Pediatric Procedural Sedation:

Ketamine and Propofol: A Complementary Pair
  • Risks and benefits are constantly being weighed in medicine.
  • Selecting the “best” medicine for procedural sedation is even more challenging as we need to consider appropriate:
    • Analgesia
    • Anxiolysis
    • Anesthesia
    • Airway Protection
    • Cardiovascular Stability
  • Every medicine has potential negative aspects that must be accounted for while hoping to augment the benefits.
  • While we all LOVE ketamine and propofol, neither Ketamine nor Propofol are perfect.
    • Ketamine:
      • Pros:
        • Has analgesic, amnestic, and dissociative properties!
        • Relatively fast onset
        • Airway reflexes are maintained
        • Supports (and even augments) cardiovascular status
      • Cons:
        • Laryngospasm risk
        • Nausea / Vomiting
        • Emergence Reactions
    • Propofol:
      • Pros:
        • Rapid onset and with
        • Predictable recovery time
        • Antiemetic effects
      • Cons:
        • Cardiovascular depression / hypotension
        • Pain at sight of injection
        • Poor analgesia over all
        • Longer term use of Propofol can lead to other issues too (not what we are talking about here).
  • In theory, the combination of the two has potential benefits:
    • Reduced vomiting.
    • Avoidance of hypotension.
    • Improved pain control.
    • Reduced dosage of both medicines.
  • In practice, the co-administration of ketamine and propofol has been found:
    • To be safe and effective. [Miller, 2019; Weisz, 2017; Scherer, 2015; Canpolat, 2012; Shah, 2011; Andolfatto, 2010]
    • To lead to less vomiting. [Shah, 2011]
    • To have slightly faster recovery times (although perhaps not clinically noticeable). [Shah, 2011]
    • To lead to good satisfaction. [Andolfatto, 2010]
    • To have similar adverse event rates with Ketamine alone. [Weisz, 2017]
    • To lead to less propofol use. [Chiaretti, 2011]
  • Whether the clinical differences between Ketamine alone and ketofol are substantial enough to warrant the advocacy of ketofol over ketamine is likely to be based on provider experience and preference.
Ketofol: How to…
  • Two separately administered medicines. [Miller, 2019]
    • Ketamine (0.5 mg/kg) given first to mitigate pain from propofol injection.
    • Followed by propofol (0.5 mg/kg).
    • Additional titrated doses of propofol as required.
  • Single mixture of both medicine administered concurrently. [Miller, 2019]
    • Commonly referred to as “ketofol.”
    • Mixture of ketamine and propofol within the same syringe.
    • Both ketamine and propofol have the same mg/ml concentration.
    • Typically used in a 1:1 ratio (same mg/kg dosage), although this is being investigated also.
Moral of the Morsel
  • Old dogs (like me) can learn new tricks. Sedation, though, shouldn’t be deemed a trick. Always be vigilant and careful!
  • Ketofol may be the best of both worlds. Yet, it is also not perfect.

References
Miller KA1, Andolfatto G2, Miner JR3, Burton JH4, Krauss BS5. Clinical Practice Guideline for Emergency Department Procedural Sedation With Propofol: 2018 Update. Ann Emerg Med. 2019 May;73(5):470-480. PMID: 30732981. [PubMed] [Read by QxMD] We update an evidence-based clinical practice guideline for the administration of propofol for emergency department procedural sedation. Both the unique considerations of using this drug in the pediatric population and the substantial new research warrant revision of the 2007 advisory. We discuss the indications, contraindications, personnel requirements, monitoring, dosing, coadministered medications, and adverse events for propofol sedation. […]
Weisz K1, Bajaj L1, Deakyne SJ2, Brou L1, Brent A1, Wathen J1, Roosevelt GE3. Adverse Events During a Randomized Trial of Ketamine Versus Co-Administration of Ketamine and Propofol for Procedural Sedation in a Pediatric Emergency Department. J Emerg Med. 2017 Jul;53(1):1-9. PMID: 28433211. [PubMed] [Read by QxMD] The co-administration of ketamine and propofol (CoKP) is thought to maximize the beneficial profile of each medication, while minimizing the respective adverse effects of each medication. […]
Scheier E1, Gadot C2, Leiba R3, Shavit I4. Sedation with the Combination of Ketamine and Propofol in a Pediatric ED: A Retrospective Case Series Analysis. Am J Emerg Med. 2015 Jun;33(6):815-7. PMID: 25819203. [PubMed] [Read by QxMD] Literature to date has suggested advantages of sedation with the combination of ketamine and propofol over ketamine alone or propofol alone. However, there is a paucity of data regarding sedation with the combination of ketamine and propofol in pediatric emergency medicine. […]
Canpolat DG1, Esmaoglu A, Tosun Z, Akn A, Boyaci A, Coruh A. Ketamine-propofol vs ketamine-dexmedetomidine combinations in pediatric patients undergoing burn dressing changes. J Burn Care Res. 2012 Nov-Dec;33(6):718-22. PMID: 22878491. [PubMed] [Read by QxMD] The aim of this study was to compare ketamine-propofol (KP) and ketamine-dexmedetomidine (KD) combinations for deep sedation and analgesia during pediatric burn wound dressing changes. After obtaining approval from the University Ethics Committee, burn wound care or wound dressing changes were performed on 60 American Society of Anesthesiologists physical status I and II inpatients aged between 8 and 60 months with second-degree burns ranging fro […]
Shah A1, Mosdossy G, McLeod S, Lehnhardt K, Peddle M, Rieder M. A blinded, randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med. 2011 May;57(5):425-33. PMID: 20947210. [PubMed] [Read by QxMD] The primary objective is to compare total sedation time when ketamine/propofol is used compared with ketamine alone for pediatric procedural sedation and analgesia. Secondary objectives include time to recovery, adverse events, efficacy, and satisfaction scores. […]
Mallory MD1, Baxter AL, Yanosky DJ, Cravero JP; Pediatric Sedation Research Consortium. Emergency physician-administered propofol sedation: a report on 25,433 sedations from the pediatric sedation research consortium. Ann Emerg Med. 2011 May;57(5):462-8. PMID: 21513827. [PubMed] [Read by QxMD] We describe the adverse events observed in a large sample of children sedated with propofol by emergency physicians and identify patient and procedure characteristics predictive of more serious adverse events. […]
Chiaretti A1, Ruggiero A, Barbi E, Pierri F, Maurizi P, Fantacci C, Bersani G, Riccardi R. Comparison of propofol versus propofol-ketamine combination in pediatric oncologic procedures performed by non-anesthesiologists. Pediatr Blood Cancer. 2011 Dec 15;57(7):1163-7. PMID: 21584935. [PubMed] [Read by QxMD] Limited data are available on the best option (short acting sedatives, opioids, or ketamine) in oncologic procedural sedation performed by non-anesthesiologists. The aim of the present prospective study is to compare the safety and efficacy of propofol-ketamine versus propofol alone, managed by trained pediatricians, in children with cancer undergoing painful procedures. […]
Andolfatto G1, Willman E. A prospective case series of pediatric procedural sedation and analgesia in the emergency department using single-syringe ketamine-propofol combination (ketofol). Acad Emerg Med. 2010 Feb;17(2):194-201. PMID: 20370749. [PubMed] [Read by QxMD] This study evaluated the effectiveness, recovery time, and adverse event profile of intravenous (IV) ketofol (mixed 1:1 ketamine-propofol) for emergency department (ED) procedural sedation and analgesia (PSA) in children. […]

The post Ketamine and Propofol (Ketofol) for Pediatric Sedation appeared first on Pediatric EM Morsels.

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