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Local anesthesia is our friend for a multitude of Emergency Department procedures. The main goal is to assure adequate coverage of the area of injury or pathology. Field block anesthesia describes the infiltration of a local anesthetic to an area surrounding a surgical and/or procedure site, resulting in anesthesia of the nerve supply of area of skin supplying the surgical field (2).This method of anesthesia is particularly effective for repair of large contaminated wounds, or incision and drainage of abscesses. The main advantage of the field block technique is that it provides anesthesia without disrupting the anatomy of the affected area (1,3).

The most commonly used anesthetic for a field block is lidocaine. One and two percent solutions are available in the ED. Onset is rapid (approximately 2-5 minutes) and lasts anywhere from 30 – 60 minutes (3).  Epinephrine can be added to lidocaine as well. It causes vasoconstriction which can decrease the clearance of the lidocaine from the desired site (3). In areas near terminal arterial branches with compromised perfusion ( e.g ear lobe, penis, tip of the nose), the use of epinephrine should be avoided (3).  Buffering of lidocaine with sodium bicarbonate (in a 9:1, lidocaine:8.4% sodium bicarbonate ratio) or warming the anesthetic to body temperature can decrease the amount of pain with injection (4). When the affected area involves infected tissue, this usually results in a more acidic environment which can hydrolyze the local anesthetic and make it less effective (4). Adding sodium bicarbonate can also increase the pH of the anesthetic solution and improve its analgesic effect. (4). Safe doses are generally 4mg/kg of lidocaine or 7mg/kg of lidocaine with epinephrine.

Performing a Field Block Equipment
  • Gloves, mask and applicable personal protective equipment
  • Syringes  (5 to 10 mL depending on the volume of anesthetic being used) 
  • Lidocaine (or desired anesthetic)
  • 25 or 27G 1 or 1.5 inch needle 
  • Chlorhexidine (or betadine)
Technique

Imagine a square or diamond shaped margin surrounding the affected area/wound. This is the ideal shape in which to perform a field block. After cleaning the area with antiseptic solution, pass the needle at one point of the diamond or square into the subcutaneous layer, and inject the anesthetic while slowly withdrawing the needle, making sure not to exit the skin. After injecting a small volume, the needle can be turned to the opposite side to inject anesthetic into the other side of the diamond of square. This method can be repeated on the opposite side of the wound at a new injection site (5).

Animated gif of the field block technique of local anesthesia. Courtesy Brad Sobolewski, MD, MEd, 2019.

It’s important to aim deep enough to target nerve branches. You don’t want to make an excessively large wheal. Additionally, it is paramount that you give the lidocaine enough time to work. You can set a 10 minute timer – if not in the midst of sedating the patient – in order to assure that the field block is successful.

Potential Complications

Common complications include inadequate anesthesia provided, warmth on palpation (with use of epinephrine), and risk of infection. Depending on the location, there is a risk of damage of nearby nerves or injection in major vessels. Allergic reactions to the anesthetic are rare but can occur, ranging anywhere from  contact dermatitis, localized angioedema to severe sysetmic reactions – such as seizure (4).  Reports of systemic toxicity following local anesthetic injections generally occur when the maximum dose is exceeded. Systemic reactions include agitation, confusion, anxiety, tinnitus, seizures, loss of consciousness,  and/or cardiovascular involvement; arrhythmias, bradycardia, cardiac arrest. 

References
  1. Moses, S., (2019, July 11). Field Block.  Retrieved from https://fpnotebook.com/Surgery/Pharm/FldBlck.htm
  2. Themes, U., ( 2017, May 14).  Peripheral Nerve Blocks and Field Blocks. Retrieved from : https://basicmedicalkey.com/peripheral-nerve-blocks-and-field-blocks/
  3. Salam, G.A. ( 2004, Feb 2001). Regional Anesthesia for Office Procedures: Part I. Head and Neck Surgeries.  Retrieved From https://www.aafp.org/afp/2004/0201/p585.html
  4. Hsu, D., (2018, Apr 3). Subcutaneous infiltration of local anesthetics. In J. F. Wiley (Ed.) Retrieved July 11, 2019 from https://www.uptodate.com/contents/subcutaneous-infiltration-of-local-anesthetics
  5. Mayeaux, E. J. Jr., ( 2011, Feb 27).  Field Block Anesthesia.  https://5minuteconsult.com/collectioncontent/30-156254/procedures/field-block-anesthesia
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PEM Cincinnati by Brad Sobolewski - 4d ago

Over the years many amazing cases have been presented during the PEMPix presentation at the American Academy of Pediatrics’ annual national Conference and Exhibition during the Section on Emergency Medicine Sessions. PEMPix Classic is a new featured series on PEMBlog that will highlight some of those classic cases.

The Case

A twelve-year old African-American male with no significant past medical history who presents with a two month history of a rash to his right arm. It started at the elbow and progressed up the arm towards the axilla. The patient denied any trauma, new contacts, change in daily routine (soaps, detergents, lotions, etc,.). He had seen his pediatrician on three occasions over the two month period and completed courses of Trimethoprim/Sulfamethoxazole and Cephalexin for a presumed soft tissue infection and a course of topical Clotrimazole with no improvement. 

This is a linear rash extending up the arm; papular, coarse, and flesh colored. There was no surrounding erythema. It is also painless, non-pruritic, and not warm to touch. What is the diagnosis?

A. Contact Dermatitis
B. Plaque Psoriasis
C. Lichen Striatus
D. Hookworm
E. Tinea Corporis

C. Lichen striatus

Lichen stratus is an uncommon, benign self limited linear inflammatory skin disorder. Most commonly seen in children around 2-3 years of age. It is known to encounter in teens as well. Girls are more commonly affected than boys. Lichen striatus may be the result of an abnormal immunologic reaction or genetic predisposition that is precipitated by some trigger such as a viral infection, trauma, hypersensitivity reaction, vaccine administration, seasonal variation, medication, or pregnancy. In this case, a Staphylococcal infection may have been the predisposing factor.

It typically presents with the sudden eruption of asymptomatic small, flat-topped, lichenoid, scaly papules in a linear array. Multiple lesions develop and then merge into linear plaques along the lines of Blaschko. They are usually asymptomatic but may be pruritic. Treatment is typically not indicated but may include topical steroids, topical retinoids, or topical calcineurin inhibitors. Most cases resolve within one year and reoccurrence is rare.

References

Shiohara T, Kano Y. Lichen planus and lichenoid dermatoses. In: Bolognia J, Jorizzo J, Schaffer J, eds. Dermatology.3rd ed. Philadelphia, PA: Elsevier/Saunders; 2012:183-202.

Wang WL, Lazar A. Lichenoidand interface dermatitis. In: Calonje E, Brenn T, Lazar A, et al, eds. McKee’s Pathology of the Skin. 4th ed. London, England: Elsevier/Saunders; 2011:219-258.

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PEM Cincinnati by Brad Sobolewski - 1w ago
The Case

A four year old male fell awkwardly in a trampoline, with his right wrist flexed, landing on the dorsum of his hand. He felt immediate pain and cried for a solid 30-minutes following the injury. Pain is most significant with palpation at the location of the radial physis and when he supinates.

AP and lateral plain radiograph of the right wrist. Courtesy of Brad Sobolewski (me)

The X-Ray is read as normal, but the young man was splinted because of ongoing pain. Over the next few days he was hesitant to use the arm and continued to be in pain at the physis and was placed in a short arm cast upon Orthopedic follow up.

The Diagnosis

A normal X-Ray does not necessarily mean that there’s not a fracture. In fact, at the 3 week mark during follow up a subsequent X-Ray was done, and it was also normal. But given the age of the patient and the persistent pain at the physis the diagnosis of a Salter Harris I fracture of the right radius was made.

Discussion

Recall that Salter-Harris is the main classification system for pediatric growth plate fractures. Read this recent post for a detailed description of the different types. Salter Harris type I fractures extend through the entirety of the growth plate (physis). The mechanism of injury is shearing across the entirety of the growth plate.

They are often NOT visible on x-ray, so a physical exam is key. In general if there is tenderness along the entirety of the physis then you should assume that there is a fracture present. If there is asymmetry at the growth plate then this is a more significant version of the Salter-Harris type I and the risk of later growth arrest is non-zero.

If there is minimal displacement or the X-ray appears normal splint and refer to Pediatric Orthopedics within 1 week for casting if pain persists. Younger patients like this one will heal quickly and may only need to be casted for 3-4 weeks.

References

Chadwick et al. The classification and prognosis of epiphyseal injuries. Injury, 1987.

Jones et al. How many children remain fracture-free during growth? a longitudinal study of children and adolescents participating in the Dunedin Multidisciplinary Health and Development Study. Osteoporos Int., 2002.

Salter-Harris Type I. Wheeless’ Textbook of Orthopedics. accessed July 11, 2019.

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Many thanks to Theresa Frey, Pediatric Emergency Medicine attending from Cincinnati Children’s, for sharing this one with me. Note: I have embedded a couple of their videos, but the file sizes are large. You can also watch them on the Annals of Emergency Medicine website.

I remember when I was an intern, and I genuinely felt bad when a small child screamed at me. now, 15_ years and 3 children of my own later I understand, bit cognitively and innately that sometimes children will just not be happy with you. They are often scared, developmentally wary fo strangers, tired and sick or injured. That’s why this article from Krauss et al. in a recent edition of Annals of Emergency Medicine is such a good read for all of you who are new to the Pediatric Emergency Department or who want to brush up on tactics to approach the frightened and anxious child.

Krauss and Krauss. Managing the Frightened Child. Annals of Emergency Medicine, 2018.

Here are some techniques, highlighted in the article with links to video examples.

Keep your distance

Approaching the scared child too quickly is a sure fire way to get them to recoil from you. Begin your approach by keeping a wide boundary. Don’t just swoop in and examine them. Know where the child is in relation to the parent and take your cues from that positioning. More fearful children will be closer to the parent. If the child is playing independent of the parent it suggests that they will be more engaged with you earlier on in the clinical encounter.

Courtesy of Annals of Emergency Medicine – accessed from https://www.annemergmed.com/article/S0196-0644(18)31560-9/fulltext Help children acclimate themselves to the environment

This article mentions several helpful techniques to help scared children get used you, and the often scary, unfamiliar environment of the Emergency Department.

  • Desensitization Allow children to touch, or “play with” items used during the examination. This can include the stethoscope, tongue depressors and the otoscope.
  • Matching Mirror the child’s posture and tone and pace. Watch for signs that they are relaxing – like uncrossing arms for example and match this.
  • Focusing attention Once the child is engaged use developmentally appropriate techniques to help get them to pay attention to you. In the preschool aged child this could be something as simple as counting. In older children discussing areas of interest are more appropriate.
Courtesy of Annals of Emergency Medicine – accessed from https://www.annemergmed.com/article/S0196-0644(18)31560-9/fulltext In a neat twist they call the final stage “Bluetooth pairing”

It’s a likely hokey I’ll say – but I think the authors were trying to engage with the modern audience through the use of this colloquial term. Plus, you engage/pair with the child and then leave their life “unpair” like a Bluetooth device, so it makes sense.

You should ideally proceed to the physical examination once you’re sure the child is engaged with you and not fearful. In all honesty this takes years of practice. But, I like this article and its videos because it will help give you some strategies to try out, and a framework to consider before you enter the room. Don’t just “wing it.” Don’t assume that “all children love you.” Remember, the ED is a scary place and the child is often ill or injured. A thoughtful approach, lost of practice and observing experts and reading material like this one can help you accelerate your engagement with the frightened child. Good luck!

References

Krauss and Krauss. Managing the Frightened Child. Annals of Emergency Medicine, 2018.

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Welcome to Facts on the Ground a new series brought to you by Nancy Rixe, Pediatric Emergency Medicine fellow from the University of Pittsburgh. Facts on the Ground is designed to be a concise literature review that helps answer common clinical questions.

This particular paper is a modern-classic, and many of you may have already identified how it changes your practice. This is a good opportunity to review a practice changing paper.

The Article

Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants
Gomez et al.
Pediatrics, 2016 

Objective

To prospectively validate the Step-by-Step approach and compare it with the Rochester criteria and the Lab-score in the identification of febrile infants ≤90 days who are at low-risk for invasive bacterial infection (IBI) as defined by the isolation of a bacterial pathogen in a blood or cerebrospinal fluid culture.

Study Design

Prospective cohort study of infants ≤90 days with fever without a source who presented to 11 European pediatric emergency departments between September 2012 and August 2014. Infants were excluded in the following circumstances: a clear source of fever was identified after a careful medical history and/or physical examination, there was no fever on arrival at the PED and the fever had been only subjectively assessed by parents on touch, without the use of a thermometer, there was an absence of 1 or more of the mandatory ancillary tests, or refusal of the parents or caregiver to participate.

All patients underwent a urine dipstick, a urine culture collected by an aseptic technique (bladder catheterization or suprapubic aspiration), white blood cell (WBC) count, C reactive protein (CRP), procalcitonin (PCT), and a blood culture. Additional tests, treatment and disposition decisions were made at the discretion of the treating provider.

The parents or caregivers of those infants managed as outpatients received a follow-up telephone call within 1 month after the initial visit at the PED to determine the course of the episode. The accuracy of the Step-by-Step approach, the Rochester criteria, and the Lab-score in identifying patients at low risk of IBI was compared.

Outcome

Of the 2185 infants included in the analysis, 504 were diagnosed with a bacterial infection (23.1%), including 87 patients (3.9%) with an IBI and 417 (19.1%) with a non-IBI. The first part of the algorithm (evaluating general appearance, age, and presence of leukocyturia) identified 79.3% of the IBI (including 22 of 26 patients with sepsis and 9 of 10 with bacterial meningitis) and 98.5% of the non-IBI.

After taking into account PCT, CRP, and ANC values, a subgroup of 991 low risk infants were identified (45.3% of the studied population) with a prevalence of IBI of 0.7%. The prevalence of potentially missed IBI was higher when using the Lab-score or the Rochester criteria than the Step by Step (p < .05). The prevalence of possible bacterial infection was similar in all the risk groups. Of the three approaches, the Step-by-Step approach demonstrated the best negative predictive value (NPV) of 99.3% and negative likelihood ratio of 0.17%. As expected, due to the relatively low prevalence of IBI (4.0%), the specificity, positive predictive value (PPV) and positive likelihood ratio were poor predictors of IBI in all three approaches.

Limitations

This study may not be entirely applicable to the US infant population due to the higher prevalence of IBI in Europe. In addition, the Rochester criteria performance was limited by the fact that the absolute band count was not available in all participating centers. Finally, this study compared the Step-By-Step approach to the Rochester criteria and the Lab Score which are not the most commonly used criteria in the evaluation of febrile infants under 90 days in the US.

The Bottom Line

The Step-by-step approach performed better than the Rochester criteria and the Lab Score in the identification of febrile infants ≤90 days at low risk for IBI. General appearance, age, and urine dipstick identified almost 80% of the IBI patients, 85% of the sepsis and 90% of the bacterial meningitis. Procalcitonin is a better biomarker to rule in an IBI, and, due its more rapid kinetic, is a more suitable biomarker in young infants who, for the great majority, present to the ED with a very early onset fever. This very short fever duration makes the evaluation of these patients even more challenging and highlights the important role of a short-term ED observation in the management of these patients.

References

Gomez et al. “Validation of the ‘Step-by-Step’ Approach in the Management of Young Febrile Infants.” Pediatrics. 2016 Aug;138(2).

Meehan et al. “Adherence to guidelines for managing the well-appearing febrile infant: assessment using a case-based, interactive survey.” Pediatr Emerg Care, 2010. (12): 875-80. 

Additional Reading

Kupperman et al. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatrics, 2019.

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PEM Cincinnati by Brad Sobolewski - 1M ago

Over the years many amazing cases have been presented during the PEMPix presentation at the American Academy of Pediatrics’ annual national Conference and Exhibition during the Section on Emergency Medicine Sessions. PEMPix Classic is a new featured series on PEMBlog that will highlight some of those classic cases.

The Case

An eight year old male with a history of eczema and seasonal allergies presents with “bumps on his eyes.” These bumps developed acutely – over the past couple fo days. Additionally, he has had bilateral watery eye discharge, eye itching and redness for the last 5 days. He denies eye pain, vision changes, purulent drainage and fever. His only daily medicine is Claritin. They tried saline eye drops.

On examination he has normal vitals and is generally well appearing. His Pupils are equal and reactive to light. He has intact extra ocular movements. The conjunctivae are injected in both eyes.  His cornea are clear with small white masses circumferentially in the peri-limbic region of the eyes bilaterally.  There is normal 20/20 vision bilaterally using short distance Snellen card. 

What is the diagnosis?

A. Atopic conjunctivitis

B. Vernal conjunctivitis

C. Seasonal allergic conjunctivitis

D. Viral conjunctivitis

E. Giant papillary conjunctivitis

B. Vernal conjunctivitis
This type of conjunctivitis is associated with other atopic diseases like asthma and allergic rhinitis and is a distinct entity from seasonal allergic conjunctivitis. It is IgE mediated – but there’s more to the picture. It is more common in males who are dark-skinned and is usually bilateral. Exacerbations are seasonal and typically occur in the spring. Symptoms include puritis, tearing /burning, photophobia, discharge (clear or mucoid), and blurred vision.
 
On examination you will see giant cobblestone-like papillae on the upper tarsal conjunctiva (Horner-Trantas dots) as well as non-purulent mucus discharge.
 
Management consists of avoiding triggers and excessive eye rubbing. Medical treatments are offered in conjunction with Ophthalmology follow up including topical antihistamines and topical mast cell stabilizers.
  References

Kraus. Vernal Conjunctivitis. American Academy of Ophthalmology. Accessed June 11, 2019.

Kumar et al. Vernal keratoconjunctivitis: a major review. Acta Ophthalmol. 2009;87(2):133. Epub 2008 Sep 11. 

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Welcome to Facts on the Ground a new series brought to you by Natan Cramer, Pediatric Emergency Medicine fellow from the University of Pittsburgh. Facts on the Ground is designed to be a concise literature review that helps answer common clinical questions.

The Article

Clinical and laboratory features of children with community-acquired pneumonia are associated with distinct radiographic presentations
Falup-Pecurariu, et al.
Europena Journal of Pediatrics, 2018

Objective

To discover differences in clinical symptoms and laboratory results of three different types of WHO-SICR (World Health Organization Standardization of Interpretation of Chest Radiographs) defined pneumonia presentations

Alveolar Pneumonia – dense opacity of a portion or entire part of lung with and without air bronchograms or pleural effusion

Non-Alveolar Pneumonia – interstitial pattern affecting both lungs, patchy areas of consolidation, peribronchial thickening

Clinical Pneumonia – absence of CXR findings

The authors hypothesized that alveolar pneumonia would be more associated with symptoms and lab findings reminiscent of bacterial infection compared to the other two pneumonia types which would be more associated with viral presentations

Study Design

This was a Multicenter Prospective, Observational Study across multiple countries in Europe that included children under the age of 59 months presenting to the ED with chest radiograph performed within 24hrs of admission and diagnosed with CAP.

Survey data regarding demographics, symptomatology, physical findings, and laboratory data (CRP, WBC count, ESR, and ANC) were obtained on the included participants. A single pediatrician blinded to the clinical and lab criteria of each patient reviewed the radiographs and sorted them into one of the three groups defined by the WHO-SICR. 

Outcome
  • 1,107 children diagnosed with CAP <5 years were included. 74.9% had Alveolar CAP, 8.9% with Non-alveolar CAP, and 16.3% with Clinical CAP. 
  • Alveolar CAP seen in older children with higher WBC, ANC, ESR, CRP.
  • Duration of fever was longer in alveolar CAP compared to the other pneumonia types.
  • More abdominal pain and vomiting in the Alveolar CAP group
  • Adjusted for age and split patients into 0-23 months of age and 24-59 months of age. Those in the younger grouping showed higher respiratory rate in alveolar CAP. The opposite was seen in the older grouping, with the respiratory rate being higher in non-alveolar CAP.
  • Clinical CAP was more similar to alveolar CAP in symptoms, but more similar to non-alveolar CAP in laboratory findings. Possibly because this reflects an early pneumonia that has not yet progressed to a radiological finding.
Weaknesses

This study builds on previous literature linking specific symptoms and laboratory markers with bacterial infection, although this is a surrogate for determining the nature of a pneumonia infection as aspiration for culture was not done for confirmation. Additionally. exclusion criteria were not mentioned in the body of the paper

The Bottom Line

Alveolar CAP is associated with more abdominal pain, higher inflammatory markers, and a presentation concerning for bacterial infection as compared to non-alveolar CAP and clinical CAP. 

References

Falup-Pecurariu, et al. Clinical and laboratory features of children with community-acquired pneumonia are associated with distinct radiographic presentations. European Journal of Pediatrics, 2018.

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Don’t Forget the Bubbles knocked it out of the park with this one. A great treatise on utility of blood cultures as well as very informative background information on the process.

Do yourself a favor and spend the 5 to 10 minutes it takes to read it, and apply what you learned during your next shift in the hospital or emergency department.

Pediatric Blood Cultures: We’re Doing it Wrong
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REVERT - Vimeo

The REVERT Maneuver was initially described by Appelboam et al. in The Lancet in 2015 as a way to more reliably induce forced valsalva to convert SVT. You can learn how to perform it in seconds, but I highly recommend you check out the original trial, because it was a very well done RCT.

This maneuver works because in addition to stimulating vagal pathways by blowing into a closed system (a medication syringe) and increasing intrathoracic pressure – you also dump extra blood into the thorax by raising the legs, which further increases intrathoaracic pressure, making the vagal response all the more potent.

References

Appelboam et al. Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. The Lancet, 2015.

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