You make tough calls when caring for acutely ill and injured children. Join us for strategy and support -- through clinical cases, research and reviews, and best-practice guidance in our ever-changing acute care landscape. Please visit our site at http://PEMplaybook.org/ for show notes and to ge…
Tim Horeczko, MD, MSCR, FACEP, FAAP
The Pediatric Emergency Playbook podcast is an invaluable resource for healthcare providers, whether they are in training or already practicing. This podcast covers a wide range of topics relevant to emergency medicine and primary care, providing both fundamental knowledge and more nuanced information. The host, Tim Horeczko, does an excellent job of citing the literature and presenting evidence-based practice guidelines. One of the standout features of this podcast is its emphasis on humanistic care and practical strategies for providing it. The content is not only informative but also engaging and inspiring.
One of the best aspects of The Pediatric Emergency Playbook podcast is its applicability to different healthcare professionals. While it is primarily targeted towards emergency medicine physicians, it also contains valuable information for primary care providers, nurses, technicians, and students. The podcasts cover common pediatric scenarios and offer best practice guidelines that can be implemented daily. The format of presenting case scenarios with multiple options for management allows listeners to actively engage with the material and learn effectively. Additionally, Tim's delivery style is entertaining and helps to enhance retention of information.
One potential drawback of this podcast is that some content may not be directly applicable to EMS (Emergency Medical Services) professionals due to long-term treatment discussions. However, there are still valuable episodes that focus on caring for children in the emergency medical field which make it worthwhile for those interested in EMS.
In conclusion, The Pediatric Emergency Playbook podcast is a highly recommended resource for healthcare professionals involved in pediatric care. It covers a wide range of topics with thoroughness and accessibility. Tim Horeczko's approach is practical, fun, and interesting, making it an enjoyable way to refresh knowledge on diagnoses and procedures that may not be encountered frequently. Whether you are a resident, physician assistant student, nurse, or seasoned clinician, this podcast provides valuable information that will improve patient care and enhance clinical skills.
pemplaybook.org/podcast/environmental-injuries-in-children/
Myth: “No olive, no problem” Reality: Rare finding, since we diagnose earlier Pyloric stenosis occurs in young infants because the pyloric sphincter hypertrophies, causing near-complete obstruction of the gastric outlet. More common in boys, preterm babies, first-born. Less common in older mothers. Association with macrolide use. Presentation Young infant arrives with forceful vomiting, but can't quite get enough to eat “the hungry, hungry, not-so-hippo”. Early presentation from 3 to 5 weeks of age: projectile vomiting Later presentation up to 12 weeks: dehydration, failure to thrive, possibly the elusive olive Labs may show hypOchloremic, hypOkalemic metabOlic acidosis: “all the Os” Watch out for hyperbilirubinemia, the “icteropyloric syndrome”: unconjugated hyperbilirubinemia from dehydration. Ultrasound shows a pylorus of greater than 3 mm wide and 14 mm long. Memory aid: 3.14 is “pi”. In pyloric stenosis, π-lorus > 3 x 14 Treatment Various options, may be deferred depending on age, availability, severity of illness, including: Pyloromyotomy — definitive. The Ramstedt pyloromyotomy is an open procedure and involves a involves a longitudinal incision along the pylorus, and blunt dissection just to level of the submucosa. The laparoscopic approach (umbilicus) is less invasive but may convey an increased risk of incomplete relief of the obstruction or perforation through the mucosa. Also, this approach involves longer OR and anesthesia time. Endoscopic balloon dilation – not as effective as pyloromyotomy; reserved for poor surgical candidates. Conservative management — an NG tube is passed by IR, and the infant slowly feeds and “grows out of it”. Atropine is sometimes used to relax the pyloric sphincter. Also usually reserved for poor surgical candidates. Selected references Aboagye J, Goldstein SD, Salazar JH, Papandria D, Okoye MT, Al-Omar K, Stewart D, Lukish J, Abdullah F. Age at presentation of common pediatric surgical conditions: Reexamining dogma. J Pediatr Surg. 2014 Jun;49(6):995-9. Bakal U, Sarac M, Aydin M, Tartar T, Kazez A. Recent changes in the features of hypertrophic pyloric stenosis. Pediatr Int. 2016 May;58(5):369-71. Sharp WW, Chan W. Images in emergency medicine. Infant with projectile vomiting. Peristaltic abdominal waves associated with infantile hypertrophic pyloric stenosis. Ann Emerg Med. 2014 Mar;63(3):289,308. Staerkle RF, Lunger F, Fink L, Sasse T, Lacher M, von Elm E, Marwan AI, Holland-Cunz S, Vuille-Dit-Bille RN. Open versus laparoscopic pyloromyotomy for pyloric stenosis. Cochrane Database Syst Rev. 2021 Mar 9;3(3):CD012827.
Hernia Myth: “If it's not strangulated, it's elective” Reality: Unlike in adults, all hernias in children are repaired at the time of diagnosis because: The risk of incarceration and strangulation is high There is a 30% risk of testicular infarction due to pressure on the gonadal vessels It is not worth messing around and “trying to navigate the system” Most groin hernias in children are indirect inguinal hernias (incomplete closure of processus vaginalis). Most indirect hernias are in boys (10-fold risk), and on the right (60%). Premature babies are at higher risk as well. 15% are bilateral. Hernias often bulge further with crying. For infants, in supine position, gently restrain their feet on the gurney. They hate it and will cry. For older children, have them laugh, cough, or blow through a syringe. The “silk glove sign” is not reliable, but if found is highly suggestive of an inguinal hernia. Roll the cord structures across the pubic tubercle. If you feel catching, like two sheets of silk rubbed together, this suggests edema from the patent processus vaginalis. Most (80%) incarcerated hernias can be reduced initially and admitted for surgery 24-48 hours after edema has improved. Use age- and patient-appropriate sedation and reduce if no peritonitis or concern for strangulation. Hydroceles usually are: non-communicating (with the abdomen); worse with crying or during the day; improve by morning; and self-resolve by age 2 without intervention. Communicating hydroceles are: usually present at birth; are associated with a patent processus vaginalis; and are often repaired later, if not resolved by 1 or 2 years of age. Girls may have an ovary incarcerated in hernial sac. Open repair or laparoscopic techniques are used. The laparoscope offers visualization of the contralateral side without significant risk of injury to vas deferens. A metachronous hernia develops later on the other side. Some surgeons opt to explore both sides at the time of diagnosis, others take conservative approach (small risk of fertility issues if both are open-explored) My take: regardless of presentation, needs admission Selected References Abdulhai S, Glenn IC, Ponsky TA. Inguinal Hernia. Clin Perinatol. 2017 Dec;44(4):865-877 Brandt ML. Pediatric hernias. Surg Clin North Am. 2008 Feb;88(1):27-43, vii-viii. doi: 10.1016/j.suc.2007.11.006. Esposito C, Escolino M, Cortese G, Aprea G, Turrà F, Farina A, Roberti A, Cerulo M, Settimi A. Twenty-year experience with laparoscopic inguinal hernia repair in infants and children: considerations and results on 1833 hernia repairs. Surg Endosc. 2017 Mar;31(3):1461-1468. Olesen CS, Mortensen LQ, Öberg S, Rosenberg J. Risk of incarceration in children with inguinal hernia: a systematic review. Hernia. 2019 Apr;23(2):245-254
Constipation as a diagnosis can be dangerous, mainly because it is a powerful anchor in our medical decision-making. Chances are, you’d be right to chalk up the pain to functional constipation — 90% of pediatric constipation is functional, multifactorial, and mostly benign — as long as it is addressed. We’re not here for “chances are“; we’re here for “why isn’t it?“ Ask yourself, could it be: Anatomic malformations: anal stenosis, anterior displaced anus, sacral hematoma Metabolic: hypothyroidism, hypercalcemia, hypokalemia, cystic fibrosis, diabetes mellitus, gluten enteropathy Neuropathic: spinal cord abnormalities, trauma, tethered cord Neuromuscular: Hirschprung disease, intestinal neuronal dysplasia, myopathies, Down syndrome, prune belly syndrome Connective tissue disorders: scleroderma, SLE, Ehlers-Danlos syndrome Drugs: opioids, antacids, antihypertensives, anticholinergics, antidepressants, sympathomimetics Ingestions: heavy metals, vitamin D overload, botulism, cow’s milk protein intolerance Red Flags Failure to thrive Abdominal distention Lack of lumbosacral curve Midline pigmentation abnormalities of the lower spine Tight, empty rectum in presence of a palpable fecal mass Gush of fluid or air from rectum on withdrawal of finger Absent anal wink You gotta push the boat out of the mud before you pray for rain. — Coach Medications for disimpaction (do this first!) Polyethylene Glycol (PEG) 3350 (Miralax): 1 to 1.5 g/kg PO daily for 3 to 6 consecutive days. Maximum daily dose: 100 g/day PO. Follow-up with maintenance dose (below) for at least 2 months (usually 6 months) Lactulose: 1.33 g/kg/dose (2 mL/kg) PO twice daily for 7 days Mineral Oil (school-aged children): 3 mL/kg PO twice daily for 7 days Medications for Maintenance (do this after disimpaction!) Polyethylene Glycol (PEG) 3350 (Miralax): 0.2 to 0.8 g/kg/day PO. Maximum daily dose: 17 g/day. Maintenance dosing for Miralax may need to be tailored; up to 1 g/day maintenance. Lactulose: 1 to 2 g/kg/day (1.5 to 3 mL/kg/day)PO divided once or twice daily. Maximum daily dose: 60 mL/day in adults. Mineral Oil: 1 to 3 mL/kg/day PO divided in 1 to 2 doses; maximum daily dose: 90 mL/day Docusate (Colace): 5 mg/kg/day PO divided QD, BID, or TID (typical adult dose 100 mg BID) Senna, Bisocodyl — complicated regimens; use your local reference Enemas Are you sure? Have you tried oral disimpaction over days? No phosphate enemas for children less than 2. Saline enemas are generally safe for all ages Be careful with the specific dose — please use your local reference Selected References Freedman SB et al. Pediatric Constipation in the Emergency Department: Evaluation, Treatment, and Outcomes. JPGN 2014;59: 327–333. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Clinical Practice Guideline: Evaluation and Treatment of Constipation in Infants and Children. JPGN 2006; 43:e1-e13. Tabbers MM et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274. Audio Player 00:00 00:0
Top 10 [details in audio] Set the stage – exude confidence and be prepared Choose the right cannula size – a smaller working IV is infinitely better than none Feeling is better than looking – trust yourself Mark the site – things get wonky when you take your hands off to disinfect Tourniquets can mess you up – try to use a holder’s hand to occlude the vein The holder rules – get as many hands on deck as you need. Tension is good – a little counter traction on the skin with your non-dominant hand helps to decrease the friction as the needle goes through the fascial layers. Stay in line – your needle is an extension of your arm Gravity is your friend – the kinder, gentler tourniquet The 3 Fs – flash, flatten, and forward. Get the flash at a 30 degree angle, flatten that angle, (advance another 1mm), and advance the plastic catheter over the needle into success
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Tuft Fracture Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009. Seymour Fracture Nellans et al. Pediatric Hand Injuires. Hand Clin. 2013 November ; 29(4): 569–578 Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009. Mallet Fracture Adolescent with mallet finger and Kirschner wire fixation. Nellans et al. Pediatric Hand Injuires. Hand Clin. 2013 November ; 29(4): 569–578 Mallet finger in splint. Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009. Volar Plate Injury Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009. Central Slip Injury Lee SA et al. Ultrasonography of the finger. Ultrasonography 2016; 35(2): 110-123. Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009. Rotational Deformity A, B: Relatively normal appearance; C: in flexion, rotational abnormality evident. Liao CY et al. Pediatric Hand and Wrist Fractures. Clin Plastic Surg 46 (2019) 425–436 Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009. Extra-Octave Fracture Mims L et al. Extra-Octave Fracture in a 14-Year-Old Basketball Player. Journal of Pediatrics. 2017; 186: P206-206 Same boy, after reduction and ulnar splint Same boy, on follow-up at 17 days Ulnar Collateral Ligament Injury Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009. Bennett Fracture radiopaedia.org Rolando Fracture wikipedia.org Selected References Kiely AL et al. The optimal management of Seymour fractures in children and adolescents: a systematic review protocol. Systematic Reviews. 2020; 9 (150). Liao CY et al. Pediatric Hand and Wrist Fractures. Clin Plastic Surg 46 (2019) 425–436 Lin JS et al. Treatment of Acute Seymour Fractures. J Pediatr Orthop. 2009; 39(1):e23-e27. Mims L et al. Extra-Octave Fracture in a 14-Year-Old Basketball Player. Journal of Pediatrics. 2017; 186: P206-206 Mohseni M et al. Ulnar Collateral Ligament Injury. Stat Pearls. 2020 Nellans et al. Pediatric Hand Injuires. Hand Clin. 2013 November ; 29(4): 569–578 Pattni A et al. Volar Plate Avulsion Injury. Eplasty. 2016; 16: ic22. Stevenson J et al. The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial. The Journal of Hand Surgery: British & European. 2003; 28(5): 388-394 Yeh PC et al. Pediatric Hand Fractures. Techniques in Orthopaedics. 2009
A spectrum — but will you recognize the blurry signposts? Temperature (core) Presentation Management Miliaria Crystallina Normal Salt-colored tiny papules, easily burst; not pruritic Modify environment; light clothing; hydration Miliaria Rubra Normal Discrimiate, red papules, not assocaited with follicles; pruritic Above plus cool compresses; calamine lotion; symptomatic tx for pruritis Miliaria Profunda Normal Confluent flesh-colored, “lumpy-bumpy”; burning Same as rubra Miliaria Pustulosa Normal May resemble rubra and/or crustallina, but pustular; h/o previous dermatitis Same as above, but may may need antibiotic if no improvement over time Heat edema Normal Swelling of feet, ankles, and/or lower legs Modify environment; elevate legs Heat syncope Normal Dizziness, orthostatic hypotension, and syncope after exertion with rapid return to normal mental status when supine Modify environment; rehydration; monitoring Heat cramps May be elevated to 40°C (104°F) Exercise-induced cramping in large muscle groups, especially legs Hydration; consider labs (Cr, total CK); may counsel to stretch muscles passively, gently Heat tetany May be elevated to 40°C (104°F) Hyperventilation with paresthesia, carpopedal spasm Modify environment; hydration; may place non-rebreather mask on low (or off) for rebreathing CO2 Heat exhaustion Elevated up to 40°C (104°F) Normal mental status, fatigue, that rapidly improves with treatment; tachycardia; GI symptoms; electrolyte abnormalities Cool environment; hydration; consider labs with severe symptoms, or if not improved Heat Stroke >40 to 40.5°C (104 to 105°F) Altered mental status; tachypneic; tachycardic with hypotension; electrolyte abnormalities; GI symptoms; often with renal failure, rhabdomyloysis, renal failure; possibly with cardiogenic shock or ARDS or DIC Rapid cooling with all modalities available (radiation, conduction, convection, evaporation); IV rehydration; labs; monitoring; ICU admission Miliaria Crystallina Miliaria Crystallina — Infant Miliaria Crystallina — Older Child Miliaria Rubra — Infant Miliaria Rubra — Infant Miliaria Rubra — Toddler Miliaria Rubra — Adolescent Miliaria Profunda Selected References Bergeron MF, Devore C, et al. Council on Sports Medicine and Fitness and Council on School Health, Policy statement—Climatic heat stress and exercising children and adolescents. Pediatrics 2011; 128:e741. Casa DJ et al. The Inter-Association Task Force for Preventing Sudden Death in Secondary School Athletics Programs: Best-Practices Recommendations. J Athl Train. 2013 Jul-Aug; 48(4): 546–553. DeFranco MJ et al. Environmental issues for team physicians. Am J Sports Med. 2008 Nov;36(11):2226-37. Ishimine P. Hyperthermia. In: Pediatric Emergency Medicine, Baren JM, Rothrock SG, Brennan JA, Brown L (Eds), Saunders Elsevier, Philadelphia 2008. p.992. Jardine DS. Heat illness and heat stroke. Pediatr Rev 2007; 28:249.
Traditional Approach: Secretory -- poisoned mucosal villi -- "the sieve" Cytotoxic -- destroyed mucosal villi -- "the shred" Osmotic -- malabsorption -- "the pull" Inflammatory -- edema, motility -- "the push" Lots of overlap, difficult to apply to clinical signs and symptoms. Bedside Approach: Fever/No Fever, Bloody/No Blood Non-bloody, febrile -- most likely viral Non-bloody, afebrile -- may be viral Bloody, febrile -- likely bacterial Non-bloody, afebrile -- full stop. Eval for Hemolytic Uremic Syndrome Workup Ask yourself -- again -- why is this not... appendicitis-torsion-intussusception-etc. Admit sick children, but most go home, so... Non-bloody, febrile -- no workup necessary; precautionary advice Non-bloody, afebrile -- be more skeptical, but generally same as above Bloody, febrile -- stool culture, follow up; do not treat empirically unless septic and admitted. Culture will dictate treat/no treat/how. Bloody, afebrile -- evaluate for hemolytic uremic syndrome, especially if under 5 years old: CBC, chemistries, UA, stool culture Evaluate Hydration Status Selected References Khan WA et al. Central Nervous System Manifestations of Childhood Shigellosis: Prevalence, Risk Factors, and Outcome. Pediatrics. 1999 Feb;103(2):E18 Lee JY et al. Diagnostic yield of stool culture and predictive factors for positive culture in patients with diarrheal illness. Medicine (Baltimore). 2017 Jul; 96(30): e7641. Nelson JD et al. Treatment of Salmonella gastroenteritis with ampicillin, amoxicillin, or placebo. Pediatrics 1980; 65:1125.
Pediatric Readiness is not just an ideal -- it's a tangible plan, a toolkit, and even better, an attitude How to improve your institution, and your own personal pediatric readiness. National Pediatric Readiness Project (NPRP) Los Angeles County Pediatric Readiness Project
Lund and Browder Chart to Estimate Burn Size in Children Parkland Formula for Burns Amount needed in addition to maintenance fluids: 4 mL/kg x BSA% = X Add 1/2 of X to maintenance over the 1st 8 hours Add the other 1/2 of X to maintenance over the next 16 hours Escharotomy Guide and the "Roman Breastplate" Yin et al. Bedside Escharotomies for Burns Classic Paragraph Selected References Mahar PD et al. Clinical differences between major burns patients deemed survivable and non-survivable on admisssion. Injury. 2015; 46:870-873. Mathis E et al. Pediatric Thermal Burns and Treatment: A Review of Progress and Future Prospects. Medicines. 2017; 4:91. Osuka A et al. Glycocalyx shedding is anhanced by age and correlates with increased fluid requirement in patients with major burns. Shock. 2017; 50(1):60-65. Sebastian R et al. Percutaneous pigtail catheter in the treatment of pneumothorax in major burns: The best alternative? Burns. 2015; e24-227 Sherren PB et al. Lethal triad in severe burns. Burns. 2014; 1492-1496. Strobel AM et al. Emergency Care of Pediatric Burns. Emerg Med Clin N AM. 2018; 441-458.
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