Podcasts about j pediatr surg

The American Board of Surgery In-Training Examination will officially be switching from reporting percentile scores by year level to percent of questions correct. What does this change mean for residents? Podcast hosts Dr. Ananya Anand, Dr. Joe L'Huillier, and Dr. Rebecca Moreci are joined by three fellow CoSEF members for this discussion: Dr. Gus Godley, Dr. Colleen McDermott, and Dr. Josh Roshal.  Hosts: –Dr. Ananya Anand, Stanford University, @AnanyaAnandMD, ananya_anand@stanford.edu –Dr. Joseph L'Huillier, University at Buffalo, @JoeLHuillier101, josephlh@buffalo.edu –Dr. Rebecca Moreci, Louisiana State University, @md_moreci, morecir@med.umich.edu –COSEF: @surgedfellows Special guests:  -Dr. Gus Godley, University of Chicago, frederick.godley@uchicagomedicine.org, @GusGodley -Dr. Colleen McDermott, University of Utah, colleen.mcdermott@hsc.utah.edu -Dr. Josh Roshal, Brigham and Women's Hospital, jaroshal@utmb.edu, @Joshua_Roshal Learning Objectives:  Listeners will:  – Understand the changes to the ABSITE score reporting by the American Board of Surgery  – Describe both positive impacts and limitations of this change from the resident perspective – List possible ideas for further refinements to standardized exams in medicine   References:  -Yeo HL, Dolan PT, Mao J, Sosa JA. Association of Demographic and Program Factors With American Board of Surgery Qualifying and Certifying Examinations Pass Rates. JAMA Surg. Jan 1 2020;155(1):22-30. doi:10.1001/jamasurg.2019.4081 https://pubmed.ncbi.nlm.nih.gov/31617872/ -Sathe TS, Wang JJ, Yap A, Zhao NW, O'Sullivan P, Alseidi A. Proposed Reforms to the American Board of Surgery In-Training Examination (ABSITE). https://www.ideasurg.pub/proposed-absite-reforms/ -Miller AT, Swain GW, Midmar M, Divino CM. How Important Are American Board of Surgery In-Training Examination Scores When Applying for Fellowships? J Surg Educ. 2010;67(3):149-151. doi:10.1016/j.jsurg.2010.02.007  https://pubmed.ncbi.nlm.nih.gov/20630424/ -Savoie KB, Kulaylat AN, Huntington JT, Kelley-Quon L, Gonzalez DO, Richards H, Besner G, Nwomeh BC, Fisher JG. The pediatric surgery match by the numbers: Defining the successful application. J Pediatr Surg. 2020;55(6):1053-1057. doi:10.1016/j.jpedsurg.2020.02.052 https://pubmed.ncbi.nlm.nih.gov/32197826/ -Alnahhal KI, Lyden SP, Caputo FJ, Sorour AA, Rowe VL, Colglazier JJ, Smith BK, Shames ML, Kirksey L. The USMLE® STEP 1 Pass or Fail Era of the Vascular Surgery Residency Application Process: Implications for Structural Bias and Recommendations. Annals of Vascular Surgery. 2023;94:195-204. doi:10.1016/j.avsg.2023.04.018  https://pubmed.ncbi.nlm.nih.gov/37120072/ -Williams M, Kim EJ, Pappas K, Uwemedimo O, Marrast L, Pekmezaris R, Martinez J. The impact of United States Medical Licensing Exam (USMLE) step 1 cutoff scores on recruitment of underrepresented minorities in medicine: A retrospective cross‐sectional study. Health Sci Rep. 2020;3(2):e2161. doi:10.1002/hsr2.161 https://pubmed.ncbi.nlm.nih.gov/32318628/ -Lucey CR, Saguil A. The Consequences of Structural Racism on MCAT Scores and Medical School Admissions: The Past Is Prologue. Academic Medicine. 2020;95(3):351. doi:10.1097/ACM.0000000000002939 https://pubmed.ncbi.nlm.nih.gov/31425184/ -Natanson H, Svrluga S. The SAT is coming back at some colleges. It's stressing everyone out. Washington Post. https://www.washingtonpost.com/education/2024/03/18/sat-test-policies-confuse-students/. Published March 19, 2024. Accessed April 5, 2024. -de Virgilio C, Yaghoubian A, Kaji A, Collins JC, Deveney K, Dolich M, Easter D, Hines OJ, Katz S, Liu T, Mahmoud A, Melcher ML, Parks S, Reeves M, Salim A, Scherer L, Takanishi D, Waxman K.. Predicting Performance on the American Board of Surgery Qualifying and Certifying Examinations: A Multi-institutional Study. Archives of Surgery. 2010;145(9):852-856. doi:10.1001/archsurg.2010.177 https://pubmed.ncbi.nlm.nih.gov/20855755/ -Weighted test content from the ABS:  https://www.absurgery.org/wp-content/uploads/2023/01/GS-ITE.pdf -USMLE program announces upcoming policy changes | USMLE. Accessed April 9, 2024. https://www.usmle.org/usmle-program-announces-upcoming-policy-changes   Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out our recent episodes here: https://app.behindtheknife.org/listen

Did you know that 80% of children with biliary atresia who undergo a Kasai procedure will still require liver transplant at some point in their life? Dr. Bade, a pediatric gastroenterologist, joins medical students Tucker Oliver and Sarah Chappell to discuss evaluation and management of infants with biliary atresia. Specifically, they will: Discuss the presentation and diagnosis of biliary atresia Explain pathophysiology behind jaundice Discuss preoperative and postoperative recommendations for the Kasai procedure Review complications and outcomes of the Kasai procedure Share advice for navigating the diagnosis of biliary atresia with families Special thanks to Dr. Rebecca Yang and Dr. Jennifer Tucker for peer reviewing this episode. FREE CME Credit (requires free sign-up): Link Coming Soon! References:  1]          P. J. Lupo et al., “Population-based birth defects data in the United States, 2010-2014: A focus on gastrointestinal defects.,” Birth Defects Res, vol. 109, no. 18, pp. 1504–1514, Nov. 2017, doi: 10.1002/bdr2.1145. [2]         J. L. Hartley, M. Davenport, and D. A. Kelly, “Biliary atresia,” The Lancet, vol. 374, no. 9702, pp. 1704–1713, Nov. 2009, doi: 10.1016/S0140-6736(09)60946-6. [3]         S. S. Sundaram, C. L. Mack, A. G. Feldman, and R. J. Sokol, “Biliary atresia: Indications and timing of liver transplantation and optimization of pretransplant care.,” Liver Transpl, vol. 23, no. 1, pp. 96–109, Jan. 2017, doi: 10.1002/lt.24640. [4]         D. Volpert, F. White, M. J. Finegold, J. Molleston, M. DeBaun, and D. H. Perlmutter, “Outcome of Early Hepatic Portoenterostomy for Biliary Atresia,” J Pediatr Gastroenterol Nutr, vol. 32, no. 3, pp. 265–269, Mar. 2001, doi: 10.1097/00005176-200103000-00006. [5]         R. Fawaz et al., “Guideline for the Evaluation of Cholestatic Jaundice in Infants: Joint Recommendations of the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition.,” J Pediatr Gastroenterol Nutr, vol. 64, no. 1, pp. 154–168, Jan. 2017, doi: 10.1097/MPG.0000000000001334. [6]         P. H. Y. Chung et al., “Life long follow up and management strategies of patients living with native livers after Kasai portoenterostomy.,” Sci Rep, vol. 11, no. 1, p. 11207, May 2021, doi: 10.1038/s41598-021-90860-w. [7]         E. H. Gad, Y. Kamel, T. A.-H. Salem, M. A.-H. Ali, and A. N. Sallam, “Short- and long-term outcomes after Kasai operation for type III biliary atresia: Twenty years of experience in a single tertiary Egyptian center-A retrospective cohort study.,” Ann Med Surg (Lond), vol. 62, pp. 302–314, Feb. 2021, doi: 10.1016/j.amsu.2021.01.052. [8]         A. M. Calinescu et al., “Cholangitis Definition and Treatment after Kasai Hepatoportoenterostomy for Biliary Atresia: A Delphi Process and International Expert Panel.,” J Clin Med, vol. 11, no. 3, Jan. 2022, doi: 10.3390/jcm11030494. [9]         S. Kiriyama et al., “Tokyo Guidelines 2018: diagnostic criteria and severity grading of acute cholangitis (with videos),” J Hepatobiliary Pancreat Sci, vol. 25, no. 1, pp. 17–30, Jan. 2018, doi: 10.1002/jhbp.512. [10]      K. Decharun, C. M. Leys, K. W. West, and S. M. E. Finnell, “Prophylactic Antibiotics for Prevention of Cholangitis in Patients With Biliary Atresia Status Post-Kasai Portoenterostomy,” Clin Pediatr (Phila), vol. 55, no. 1, pp. 66–72, Jan. 2016, doi: 10.1177/0009922815594760. [11]      E. Jung, W.-H. Park, and S.-O. Choi, “Late complications and current status of long-term survivals over 10 years after Kasai portoenterostomy.,” J Korean Surg Soc, vol. 81, no. 4, pp. 271–5, Oct. 2011, doi: 10.4174/jkss.2011.81.4.271. [12]      S. S. Sundaram et al., “Health related quality of life in patients with biliary atresia surviving with their native liver.,” J Pediatr, vol. 163, no. 4, pp. 1052–7.e2, Oct. 2013, doi: 10.1016/j.jpeds.2013.04.037. [13]      B. L. Shneider et al., “Efficacy of fat-soluble vitamin supplementation in infants with biliary atresia.,” Pediatrics, vol. 130, no. 3, pp. e607-14, Sep. 2012, doi: 10.1542/peds.2011-1423. [14]      J. P. Molleston and B. L. Shneider, “Preventing variceal bleeding in infants and children: is less more?,” Gastroenterology, vol. 145, no. 4, pp. 719–22, Oct. 2013, doi: 10.1053/j.gastro.2013.08.026. [15]      G. Grisotti and R. A. Cowles, “Complications in pediatric hepatobiliary surgery,” Semin Pediatr Surg, vol. 25, no. 6, pp. 388–394, Dec. 2016, doi: 10.1053/j.sempedsurg.2016.10.004. [16]      F. R. Sinatra, “Consultation with the Specialist: Liver Transplantation for Biliary Atresia,” Pediatr Rev, vol. 22, no. 5, pp. 166–168, May 2001, doi: 10.1542/pir.22-5-166. [17]      I. Sriram and D. Nicklas, “Biliary Atresia,” Pediatr Rev, vol. 43, no. 11, pp. 659–661, Nov. 2022, doi: 10.1542/pir.2021-005287. [18]      L. H. Rodijk et al., “Parental wellbeing after diagnosing a child with biliary atresia: A prospective cohort study.,” J Pediatr Surg, vol. 57, no. 4, pp. 649–654, Apr. 2022, doi: 10.1016/j.jpedsurg.2021.05.026. [19]      A. Sanchez-Valle, N. Kassira, V. C. Varela, S. C. Radu, C. Paidas, and R. S. Kirby, “Biliary Atresia: Epidemiology, Genetics, Clinical Update, and Public Health Perspective.,” Adv Pediatr, vol. 64, no. 1, pp. 285–305, Aug. 2017, doi: 10.1016/j.yapd.2017.03.012.

Please join Drs. Brian Gray, Amanda Jensen and Manisha Bhatia from Indiana University as they discuss the nuances of 3 common pediatric general surgery scenarios.  Journal Article links:  Nguyen HN, Navarro OM, Bloom DA, Feinstein KA, Guillerman RP, Munden MM, et al. Ultrasound for Midgut Malrotation and Midgut Volvulus: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2022;218(6):931-9. https://pubmed.ncbi.nlm.nih.gov/35107311/ Plut D, Phillips GS, Johnston PR, Lee EY. Practical Imaging Strategies for Intussusception in Children. AJR Am J Roentgenol 2020;215(6):1449-63. https://pubmed.ncbi.nlm.nih.gov/33084362/ Markel TA, Scott MR, Stokes SM, Ladd AP. A randomized trial to assess advancement of enteral feedings  following surgery for hypertrophic pyloric stenosis. J Pediatr Surg 2017;52(4):534-9. https://pubmed.ncbi.nlm.nih.gov/27829521/ St Peter SD, Holcomb GW, 3rd, Calkins CM, Murphy JP, Andrews WS, Sharp RJ, et al. Open versus  laparoscopic pyloromyotomy for pyloric stenosis: a prospective, randomized trial. Ann Surg  2006;244(3):363-70. https://pubmed.ncbi.nlm.nih.gov/16926562/ Dalton BG, Gonzalez KW, Boda SR, Thomas PG, Sherman AK, St Peter SD. Optimizing fluid resuscitation in  hypertrophic pyloric stenosis. J Pediatr Surg 2016;51(8):1279-82. https://pubmed.ncbi.nlm.nih.gov/26876090/ Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other pediatric surgery episodes here: https://behindtheknife.org/podcast-category/pediatric/

Please join Drs. Brian Gray, Amanda Jensen, and Manisha Bhatia from Indiana University as they discuss Hirschsprung disease in regard to variability of the transition zone and surgical operative and pathologic diagnosis reporting in pediatric surgery. Journal Article links:  Veras LV, Arnold M, Avansino JR, Bove K, Cowles RA, Durham MM, et al. Guidelines for synoptic reporting of surgery and pathology in Hirschsprung disease. J Pediatr Surg 2019;54(10):2017-23. https://pubmed.ncbi.nlm.nih.gov/30935730/ Thakkar HS, Blackburn S, Curry J, De Coppi P, Giuliani S, Sebire N, et al. Variability of the transition zone length in Hirschsprung disease. J Pediatr Surg 2020;55(1):63-6. https://pubmed.ncbi.nlm.nih.gov/31706615/ Coyle D, O'Donnell AM, Tomuschat C, Gillick J, Puri P. The Extent of the Transition Zone in Hirschsprung Disease. J Pediatr Surg 2019;54(11):2318-24. https://pubmed.ncbi.nlm.nih.gov/31079866/ **Specialty team application link - https://forms.gle/DwrRcMYDaP3a3LaQA Please email hello@behindtheknife.org with any questions. Please visit https://behindtheknife.org to access other high-yield surgical education podcasts, videos and more.   If you liked this episode, check out other pediatric surgery episodes here: https://behindtheknife.org/podcast-category/pediatric/

Here's the July 2022 issue of JPS article highlights. This time we're talking to Dr. Mary Brindle and authors Drs. Erik Skarsgard, Dunya Moghul and Sophie Carr. Hosts: Ellen Encisco, Em Tombash, Cecilia Gigena Articles: Wang Z, Han Q, Wang J, Yao W, Wang L, Li K. Rapamycin induces autophagy and apoptosis in Kaposiform hemangioendothelioma primary cells in vitro. J Pediatr Surg. 2022 Jul;57(7):1274-1280. doi: 10.1016/j.jpedsurg.2022.02.032. Epub 2022 Mar 13. PMID: 35428493. https://pubmed.ncbi.nlm.nih.gov/35428493/ Moghul D. Mission impossible, made possible: Two GAP Fellows escape from Afghanistan. J Pediatr Surg. 2022 Jul;57(7):1189-1195. doi: 10.1016/j.jpedsurg.2022.02.021. Epub 2022 Feb 27. PMID: 35410710. https://pubmed.ncbi.nlm.nih.gov/35410710/ Carr S, Gogal C, Afshar K, Ting J, Skarsgard E. Optimizing skin antisepsis for neonatal surgery: A quality improvement initiative. J Pediatr Surg. 2022 Jul;57(7):1235-1241. doi: 10.1016/j.jpedsurg.2022.02.027. Epub 2022 Mar 13. PMID: 35397873. https://pubmed.ncbi.nlm.nih.gov/35397873/ Don't forget to like and subscribe to see more entertaining medical educational videos! https://www.youtube.com/c/StayCurrentMD See more lectures, articles, and more on the Stay Current app: https://globalcastmd.com/stay-current-app-download

We're back with a new topic, discussing surgical management with Drs. Michael Helmrath and Paul Wales from Intestinal Rehabilitation Center at Cincinnati Children's Hospital. Hosts: Ellen Encisco & Em Tombash Resources: Bianchi A. Intestinal loop lengthening--a technique for increasing small intestinal length. J Pediatr Surg. 1980 Apr;15(2):145-51. doi: 10.1016/s0022-3468(80)80005-4. PMID: 7373489. https://pubmed.ncbi.nlm.nih.gov/7373489/ Bianchi A. Intestinal lengthening: an experimental and clinical review. J R Soc Med. 1984;77 Suppl 3(Suppl 3):35-41. PMID: 6471060; PMCID: PMC1440516. https://pubmed.ncbi.nlm.nih.gov/6471060/ Bianchi A. Longitudinal intestinal lengthening and tailoring: results in 20 children. J R Soc Med. 1997 Aug;90(8):429-32. doi: 10.1177/014107689709000804. PMID: 9306995; PMCID: PMC1296456. https://pubmed.ncbi.nlm.nih.gov/9306995/ Bianchi A. Experience with longitudinal intestinal lengthening and tailoring. Eur J Pediatr Surg. 1999 Aug;9(4):256-9. doi: 10.1055/s-2008-1072258. PMID: 10532271. https://pubmed.ncbi.nlm.nih.gov/10532271/ Kim HB, Fauza D, Garza J, Oh JT, Nurko S, Jaksic T. Serial transverse enteroplasty (STEP): a novel bowel lengthening procedure. J Pediatr Surg. 2003 Mar;38(3):425-9. doi: 10.1053/jpsu.2003.50073. PMID: 12632361. https://pubmed.ncbi.nlm.nih.gov/12632361/ Kim HB, Lee PW, Garza J, Duggan C, Fauza D, Jaksic T. Serial transverse enteroplasty for short bowel syndrome: a case report. J Pediatr Surg. 2003 Jun;38(6):881-5. doi: 10.1016/s0022-3468(03)00115-5. PMID: 12778385. https://pubmed.ncbi.nlm.nih.gov/12778385/ Garnett GM, Kang KH, Jaksic T, Woo RK, Puapong DP, Kim HB, Johnson SM. First STEPs: serial transverse enteroplasty as a primary procedure in neonates with congenital short bowel. J Pediatr Surg. 2014 Jan;49(1):104-7; discussion 108. doi: 10.1016/j.jpedsurg.2013.09.037. Epub 2013 Oct 5. PMID: 24439591. https://pubmed.ncbi.nlm.nih.gov/24439591/ Don't forget to like and subscribe to see more entertaining medical educational videos! https://www.youtube.com/c/StayCurrentMD See more lectures, articles, and more on the Stay Current app: https://globalcastmd.com/stay-current-app-download

Here's the June 2022 issue of JPS article highlights. This time we're talking to Dr. Nicole Chandler and authors Drs. Elizabeth Beierle, Marcus Malek, Biren Modi, Amelia Collings and Katherine Flynn O'Brien. Hosts: Ellen Encisco, Em Tombash 00:00 Introduction 01:56 Impact of “Stay-at-Home” orders on non-accidental trauma - A multi-institutional study 06:22 Metastatic human hepatoblastoma cells exhibit enhanced tumorigenicity, invasiveness and a stem cell-like phenotype 09:18 Interhospital variability in localization techniques for small pulmonary nodules in children- A pediatric surgical oncology research collaborative study 12:26 Puberty and growth in patients with pediatric intestinal failure 15:08 Conclusion Articles: Collings AT, Farazi M, Van Arendonk K, Fallat ME, Minneci PC, Sato TT, Speck KE, Deans KJ, Falcone RA, Foley DS, Fraser JD, Keller MS, Kotagal M, Landman MP, Leys CM, Markel T, Rubalcava N, St Peter SD, Flynn-O'Brien KT; Midwest Pediatric Surgery Consortium. Impact of "Stay-at-Home" orders on non-accidental trauma: A multi-institutional study. J Pediatr Surg. 2022 Jun;57(6):1062-1066. https://www.jpedsurg.org/article/S0022-3468(22)00130-0/fulltext Marayati R, Julson JR, Bownes LV, Quinn CH, Hutchins SC, Williams AP, Markert HR, Beierle AM, Stewart JE, Hjelmeland AB, Mroczek-Musulman E, Beierle EA. Metastatic human hepatoblastoma cells exhibit enhanced tumorigenicity, invasiveness and a stem cell-like phenotype. J Pediatr Surg. 2022 Jun;57(6):1018-1025. https://www.jpedsurg.org/article/S0022-3468(22)00129-4/fulltext Morgan KM, Anderson KT, Johnston ME, Dasgupta R, Crowley JJ, Fahy AS, Lapidus-Krol E, Baertschiger RM, Lautz TB, Many BT, Marquart JP, Gainer H, Lal DR, Rich BS, Glick RD, MacArthur TA, Polites SF, Kastenberg ZJ, Short SS, Meyers RL, Talbot L, Abdelhafeez A, Prajapati H, Davidoff AM, Rubaclava N, Newman E, Ehrlich PF, Rothstein DH, Roach JP, Ladd P, Janek KC, Le HD, Leraas HJ, Tracy ET, Bisset L, Mora MC, Warren P, Aldrink JH, Malek MM. Interhospital variability in localization techniques for small pulmonary nodules in children: A pediatric surgical oncology research collaborative study. J Pediatr Surg. 2022 Jun;57(6):1013-1017. https://www.jpedsurg.org/article/S0022-3468(22)00139-7/fulltext Culbreath K, Keefe G, Staffa SJ, Wynne N, Grimstad F, Jimenez L, Jaksic T, Modi BP. Puberty and growth in patients with pediatric intestinal failure. J Pediatr Surg. 2022 Jun;57(6):1045-1049. https://www.jpedsurg.org/article/S0022-3468(22)00132-4/fulltext Don't forget to like and subscribe to see more entertaining medical educational videos! See more lectures, articles, and more on the Stay Current app: https://www.globalcastmd.com/stay-current-app-download

Dr. José Campos is back, this time helping us review some of the latest literature on the diagnosis and management of Esophageal Atresia in children. In this podcast, we're reviewing a typical case with Dr. Todd Ponsky and incorporating literature from the last few years. Hosts: Rod Gerardo, Ellen Encisco and Em Tombash Don't forget to register for the 10th Annual Update Course which will take place on August 30 2022, 9am EST! https://globalcastmd.wufoo.com/forms/zjvig871ne79wa/ Articles if you want to follow along; Lal DR, Gadepalli SK, Downard CD, Ostlie DJ, Minneci PC, Swedler RM, Chelius TH, Cassidy L, Rapp CT, Billmire D, Bruch S, Burns RC, Deans KJ, Fallat ME, Fraser JD, Grabowski J, Hebel F, Helmrath MA, Hirschl RB, Kabre R, Kohler J, Landman MP, Leys CM, Mak GZ, Raque J, Rymeski B, Saito JM, St Peter SD, von Allmen D, Warner BW, Sato TT; Midwest Pediatric Surgery Consortium. Challenging surgical dogma in the management of proximal esophageal atresia with distal tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium. J Pediatr Surg. 2018 Jul;53(7):1267-1272. doi: 10.1016/j.jpedsurg.2017.05.024. Epub 2017 Jun 1. PMID: 28599967. https://pubmed.ncbi.nlm.nih.gov/28599967/ *** LaRusso K, Joharifard S, Lakabi R, Nimer N, Shahi A, Kasasni SM, Lévesque D, Moreau B, Aspirot A, Laberge JM, Faure C, Emil S. Effect of transanastomotic feeding tubes on anastomotic strictures in patients with esophageal atresia and tracheoesophageal fistula: The Quebec experience. J Pediatr Surg. 2022 Jan;57(1):41-44. doi: 10.1016/j.jpedsurg.2021.09.014. Epub 2021 Sep 20. PMID: 34666898. https://www.jpedsurg.org/article/S0022-3468(21)00625-4/pdf *** Anand S, Singh A, Krishnan N, Yadav DK. Whether prophylactic intraoperative chest drain insertion in esophageal atresia-tracheoesophageal fistula is an evidence-based practice or just a prejudice: A systematic review and meta-analysis. J Pediatr Surg. 2022 Aug;57(8):1554-1560. doi: 10.1016/j.jpedsurg.2021.06.015. Epub 2021 Jul 8. PMID: 34284871. https://pubmed.ncbi.nlm.nih.gov/34284871/ *** Kainth D, Anand S, Singh A, Bajpai M. Impact of preservation of the azygos vein during surgical repair of esophageal atresia-tracheoesophageal fistula (EA-TEF): a systematic review and meta-analysis. Pediatr Surg Int. 2021 Aug;37(8):983-989. doi: 10.1007/s00383-021-04913-2. Epub 2021 Apr 27. PMID: 33907863. https://pubmed.ncbi.nlm.nih.gov/33907863/ Don't forget to like and subscribe to see more entertaining medical educational videos! See more lectures, articles, and more on the Stay Current app: https://www.globalcastmd.com/stay-current-app-download

We're back with the April issue of JPS article highlights. This time we're talking to Dr. Paul Tam and authors Dr. Natalie Lopyan and Dr. Christina Theodorou. Hosts: Em Tombash, Rod Gerardo, Brittany Levy Lopyan NM, Perrone EE, Gadepalli SK, et al. Current status of subspecialization in pediatric surgery: A focus on fetal surgery. J Pediatr Surg. 2022;57(4):610-615. doi:10.1016/j.jpedsurg.2021.05.008 Theodorou CM, Stokes SC, Jackson JE, et al. Efficacy of clinical-grade human placental mesenchymal stromal cells in fetal ovine myelomeningocele repair. J Pediatr Surg. 2022;57(4):753-758. doi:10.1016/j.jpedsurg.2021.05.025 Dzhuma K, Powis M, Vujanic G, et al. Surgical management, staging, and outcomes of Wilms tumours with intravascular extension: Results of the IMPORT study. J Pediatr Surg. 2022;57(4):572-578. doi:10.1016/j.jpedsurg.2021.08.023

Please join Drs. Brian Gray, Amanda Jensen and Manisha Bhatia from Indiana University as they discuss TEF management and the use of a post-operative transanastomotic feeding tubes in pediatric surgery. Journal Article links:  Wang, C., Feng, L., Li, Y., & Ji, Y. (2018). What is the impact of the use of transanastomotic feeding tube on patients with esophageal atresia: a systematic review and meta-analysis. BMC Pediatr, 18(1), 385. doi:10.1186/s12887-018-1359-5 https://pubmed.ncbi.nlm.nih.gov/30541487/ Bence, C. M., Rymeski, B., Gadepalli, S., Sato, T. T., Minneci, P. C., Downard, C., . . . Midwest Pediatric Surgery, C. (2021). Clinical outcomes following implementation of a management bundle for esophageal atresia with distal tracheoesophageal fistula. J Pediatr Surg, 56(1), 47-54. doi:10.1016/j.jpedsurg.2020.09.049 https://pubmed.ncbi.nlm.nih.gov/33131776/ LaRusso, K., Joharifard, S., Lakabi, R., Nimer, N., Shahi, A., Kasasni, S. M., . . . Emil, S. (2022). Effect of transanastomotic feeding tubes on anastomotic strictures in patients with esophageal atresia and tracheoesophageal fistula: The Quebec experience. J Pediatr Surg, 57(1), 41-44. doi:10.1016/j.jpedsurg.2021.09.014 https://pubmed.ncbi.nlm.nih.gov/34666898/ Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

We're back with the March issue of JPS article highlights. This time we're talking to editor Dr.Mikko Pakarinen and authors Drs. Selcuk Kilic, Scott Short and Michael Rollins with Dr. Todd Ponsky. Hosts: Ellen Encisco, Em Tombash & Brittany Levy Articles: Neogi S, Banerjee A, Panda SS, Ratan SK, Narang R. Laparoscopic versus open appendicectomy for complicated appendicitis in children: A systematic review and meta-analysis. J Pediatr Surg. 2022 Mar;57(3):394-405. doi: 10.1016/j.jpedsurg.2021.07.005. Epub 2021 Jul 13. PMID: 34332757. Kılıç ŞS, Serdar İskit H. Management and clinical outcomes of congenital esophageal stenosis in pediatric patients: Experience of a tertiary referral center. J Pediatr Surg. 2022 Mar;57(3):518-525. doi: 10.1016/j.jpedsurg.2021.06.006. Epub 2021 Jun 25. PMID: 34229876. Short SS, Zobell S, Gaddis K, Mammen L, Wynne E, Rollins MD. Use of expedited post-operative protocol for children undergoing appendicostomy reduces length of hospitalization. J Pediatr Surg. 2022 Mar;57(3):406-409. doi: 10.1016/j.jpedsurg.2021.03.053. Epub 2021 Apr 5. PMID: 33962760.

Dr. José Campos is back, this time helping us review some of the latest literature on the diagnosis and management of CPAM in children. In this podcast, we're reviewing a typical case with Dr. Todd Ponsky and incorporating literature from the last few years. Hosts: Rod Gerardo and Ellen Encisco Articles if you want to follow along; Kunisaki SM, Lal DR, Saito JM, Fallat ME, St Peter SD, Fox ZD, Heider A, Chan SS, Boyd KP, Burns RC, Deans KJ, Gadepalli SK, Hirschl RB, Kabre R, Landman MP, Leys CM, Mak GZ, Minneci PC, Wright TN, Helmrath MA; MIDWEST PEDIATRIC SURGERY CONSORTIUM. Pleuropulmonary Blastoma in Pediatric Lung Lesions. Pediatrics. 2021 Apr;147(4):e2020028357. doi: 10.1542/peds.2020-028357. Epub 2021 Mar 24. PMID: 33762310. https://pubmed.ncbi.nlm.nih.gov/33762310/ Jelin EB, O'Hare EM, Jancelewicz T, Nasr I, Boss E, Rhee DS. Optimal timing for elective resection of asymptomatic congenital pulmonary airway malformations. J Pediatr Surg. 2018 May;53(5):1001-1005. doi: 10.1016/j.jpedsurg.2018.02.032. Epub 2018 Feb 10. PMID: 29514740. https://pubmed.ncbi.nlm.nih.gov/29514740/ Elhattab A, Elsaied A, Wafa T, Jugie M, Delacourt C, Sarnacki S, Aly K, Khen-Dunlop N. Thoracoscopic surgery for congenital lung malformations: Does previous infection really matter? J Pediatr Surg. 2021 Nov;56(11):1982-1987. doi: 10.1016/j.jpedsurg.2021.01.036. Epub 2021 Jan 27. PMID: 33573805. https://pubmed.ncbi.nlm.nih.gov/33573805/ Downard CD, Calkins CM, Williams RF, Renaud EJ, Jancelewicz T, Grabowski J, Dasgupta R, McKee M, Baird R, Austin MT, Arnold MA, Goldin AB, Shelton J, Islam S. Treatment of congenital pulmonary airway malformations: a systematic review from the APSA outcomes and evidence based practice committee. Pediatr Surg Int. 2017 Sep;33(9):939-953. doi: 10.1007/s00383-017-4098-z. Epub 2017 Jun 6. PMID: 28589256. https://pubmed.ncbi.nlm.nih.gov/28589256/ Cook J, Chitty LS, De Coppi P, Ashworth M, Wallis C. The natural history of prenatally diagnosed congenital cystic lung lesions: long-term follow-up of 119 cases. Arch Dis Child. 2017 Sep;102(9):798-803. doi: 10.1136/archdischild-2016-311233. Epub 2017 Jun 5. PMID: 28584070. https://pubmed.ncbi.nlm.nih.gov/28584070/

Anal fissures, hemorrhoids, and abscesses are not a very comfortable topic, but they are fairly common in the pediatric population. Join Dr. Nelson Rosen for the latest treatment algorithms and recommendations regarding pediatric anal pathology. Rentea RM, St Peter SD. Pediatric Rectal Prolapse. Clin Colon Rectal Surg. 2018;31(2):108-116. doi:10.1055/s-0037-1609025 https://pubmed.ncbi.nlm.nih.gov/29487493/ Christison-Lagay ER, Hall JF, Wales PW, et al. Nonoperative management of perianal abscess in infants is associated with decreased risk for fistula formation. Pediatrics. 2007;120(3):e548-e552. doi:10.1542/peds.2006-3092 https://pubmed.ncbi.nlm.nih.gov/17682038/ Rosen NG, Gibbs DL, Soffer SZ, Hong A, Sher M, Peña A. The nonoperative management of fistula-in-ano. J Pediatr Surg. 2000;35(6):938-939. doi:10.1053/jpsu.2000.6931 https://pubmed.ncbi.nlm.nih.gov/10873039/ Goddard GR, Lim IIP, Cheng YC, et al. A child presents with perianal symptoms - how often is this Crohn's disease?. J Pediatr Surg. 2021;56(9):1618-1622. doi:10.1016/j.jpedsurg.2020.11.016 https://pubmed.ncbi.nlm.nih.gov/33280851/ 00:00 Introduction 01:12 Anal Anatomy 02:18 Anal Fissure 05:26 Hemorrhoids 07:20 Rectal Prolapse 10:26 Perianal Abscess 16:18 Pilonidal Disease

Please join Drs. Brian Gray, Amanda Jensen and Manisha Bhatia from Indiana University as they discuss neuroblastoma management in pediatric surgery. Journal Article links:  Croteau N, Nuchtern J, LaQuaglia MP. Management of Neuroblastoma in Pediatric Patients. Surg Oncol Clin N Am 2021;30(2):291-304. https://pubmed.ncbi.nlm.nih.gov/33706901/ Madonna MB, Newman E. Handbook for Children with Neuroblastoma. Updated Spring 2018. Cancer Committee American Pediatric Surgical Association. 2018. https://www.pedsurglibrary.com/apsa/ub?cmd=repview&type=682-76&name=4_1884004_PDF https://www.pedsurglibrary.com/apsa/ub?cmd=repview&type=682-76&name=4_1884004_PDF Newman EA, Abdessalam S, Aldrink JH, Austin M, Heaton TE, Bruny J, et al. Update on neuroblastoma. J Pediatr Surg 2019;54(3):383-9. https://pubmed.ncbi.nlm.nih.gov/30305231/ Nuchtern JG, London WB, Barnewolt CE, Naranjo A, McGrady PW, Geiger JD, et al. A prospective study of expectant observation as primary therapy for neuroblastoma in young infants: a Children's Oncology Group study. Ann Surg 2012;256(4):573-80. https://pubmed.ncbi.nlm.nih.gov/22964741/ Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.  

    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.  

En este nuevo episodio realizo un repaso muy breve del shock index o índice de shock. Espero que les guste y sea de utilidad. Referencias: - Café Club del Conocimiento. Antonio Pérez Alonso y Susana Simo. Shock. - Lee YT, Bae BK, Cho YM, Park SC, Jeon CH, Huh U, Lee DS, Ko SH, Ryu DM, Wang IJ. Reverse shock index multiplied by Glasgow coma scale as a predictor of massive transfusion in trauma. Am J Emerg Med. 2021 Aug;46:404-409. doi: 10.1016/j.ajem.2020.10.027. Epub 2020 Oct 20. PMID: 33143960. - Kimura, A., Tanaka, N. El índice de choque inverso multiplicado por la puntuación de la escala Coma de Glasgow (rSIG) es una medida simple con alta capacidad discriminante para el riesgo de mortalidad en pacientes traumatizados: un análisis del Banco de Datos de Trauma de Japón. Crit Care 22,87 (2018). https://doi.org/10.1186/s13054-018-2014-0 - El-Menyar A, Goyal P, Tilley E, Latifi R. The clinical utility of shock index to predict the need for blood transfusion and outcomes in trauma. J Surg Res. 2018 Jul;227:52-59. doi: 10.1016/j.jss.2018.02.013. Epub 2018 Mar 12. PMID: 29804862. - Marín Barboza, L., & Muñoz, R. (2020). Índice de choque. Revista Ciencia Y Salud Integrando Conocimientos, 4(4), Pág. 31–38. https://doi.org/10.34192/cienciaysalud.v4i4.168 - NAEMT. Manual proveedor PHTLS. Ed. 9. 2018. - Olaussen A, Blackburn T, Mitra B, Fitzgerald M. Review article: Shock Index for prediction of critical bleeding post-trauma: A systematic review: Shock Index for Critical Bleeding. Emerg Med Australas. junio de 2014;26(3):223-8. - Mitra B, Fitzgerald M, Chan J. The utility of a shock index≥1 as an indication for pre-hospital oxygen carrier administration in major trauma. Injury. enero de 2014;45(1):61-5. - Al Jalbout N, Balhara KS, Hamade B, Hsieh Y-H, Kelen GD, Bayram JD. Shock index as a predictor of hospital admission and inpatient mortality in a US national database of emergency departments. Emerg Med J. mayo de 2019;36(5):293-7. - Edla S, Reisner AT, Liu J, Convertino VA, Carter R, Reifman J. In reply to “Utility of shock index calculation in hemorrhagic trauma”. Am J Emerg Med. julio de 2015;33(7):978-9. - Saffouri E, Blackwell C, Laursen SB, Laine L, Dalton HR, Ngu J, et al. The Shock Index is not accurate at predicting outcomes in patients with upper gastrointestinal bleeding. Aliment Pharmacol Ther [Internet]. 23 de octubre de 2019 [citado 31 de octubre de 2019]; Disponible en: http://doi.wiley.com/10.1111/apt.15541 - Campos-Serra A, Montmany-Vioque S, Rebasa-Cladera P, Llaquet-Bayo H, Gràcia-Roman R, Colom-Gordillo A, et al. Aplicación del Shock Index como predictor de hemorragia en el paciente politraumático. Cir Esp. octubre de 2018;96(8):494-500. - Kristensen AKB, Holler JG, Hallas J, Lassen A, Shapiro NI. Is Shock Index a Valid Predictor of Mortality in Emergency Department Patients With Hypertension, Diabetes, High Age, or Receipt of β- or Calcium Channel Blockers? Ann Emerg Med. enero de 2016;67(1):106-113.e6. - Abe N, Miura T, Miyashita Y, Hashizume N, Ebisawa S, Motoki H, et al. Long-Term Prognostic Implications of the Admission Shock Index in Patients With Acute Myocardial Infarction Who Received Percutaneous Coronary Intervention. Angiology. abril de 2017;68(4):339-45. - Yu T, Tian C, Song J, He D, Sun Z, Sun Z. Derivation and Validation of Shock Index as a parameter for Predicting Long-term Prognosis in Patients with Acute Coronary Syndrome. Sci Rep. diciembre de 2017;7(1):11929.1.2.3.4.5.6.7.8.9. - Kobayashi A, Misumida N, Luger D, Kanei Y. Shock Index as a predictor for In-hospital mortality in patients with non-ST-segment elevation myocardial infarction. Cardiovasc Revasc Med. junio de 2016;17(4):225-8. - El-Menyar A, Sulaiman K, Almahmeed W, Al-Motarreb A, Asaad N, AlHabib KF, et al. Shock Index in Patients Presenting With Acute Heart Failure: A Multicenter Multinational Observational Study. Angiology. noviembre de 2019;70(10):938-46. - Middleton, Smith, Bedford, Neilly, Myint. Shock Index Predicts Outcome in Patients with Suspected Sepsis or Community-Acquired Pneumonia: A Systematic Review. J Clin Med. 31 de julio de 2019;8(8):1144. - Acker SN, Ross JT, Partrick DA, Tong S, Bensard DD. Pediatric specific shock index accurately identifies severely injured children. J Pediatr Surg. febrero de 2015;50(2):331-4. - Nordin A, Shi J, Wheeler K, Xiang H, Kenney B. Age-adjusted shock index: From injury to arrival. J Pediatr Surg. mayo de 2019;54(5):984-8. - Strutt J, Flood A, Kharbanda AB. Shock Index as a Predictor of Morbidity and Mortality in Pediatric Trauma Patients: Pediatr Emerg Care. febrero de 2019;35(2):132-7. - Hashmi A, Rhee P, Pandit V, Kulvatunyou N, Tang A, O’Keeffe T, et al. Shock Index Predicts Mortality in Geriatric Trauma Patients: An Analysis of The National Trauma Data Bank. J Surg Res. febrero de 2014;186(2):687. - Chung J-Y, Hsu C-C, Chen J-H, Chen W-L, Lin H-J, Guo H-R, et al. Shock index predicted mortality in geriatric patients with influenza in the emergency department. Am J Emerg Med. marzo de 2019;37(3):391-4. - Kuo SCH, Kuo P-J, Hsu S-Y, Rau C-S, Chen Y-C, Hsieh H-Y, et al. The use of the reverse shock index to identify high-risk trauma patients in addition to the criteria for trauma team activation: a cross-sectional study based on a trauma registry system. BMJ Open. junio de 2016;6(6): e011072. - Jiang L, Caputo ND, Chang BP. Respiratory adjusted shock index for identifying occult shock and level of Care in Sepsis Patients. Am J Emerg Med. marzo de 2019;37(3):506-9.10.11.12.13.14.15.16.17.18.19.38 - Laura Pariente Juste, Maylin Koo Gómez, Antonia Bonet Burguera, Raquel Reyes García, Lourdes Pérez García, Irene Macía Tejada Índices de shock prehospitalario y hospitalario como predictores de transfusión masiva en la atención inicial del paciente politraumático Emergencias 2021;33:29-34

Please join Drs. Brian Gray, Amanda Jensen and Manisha Bhatia from Indiana University as they discuss ovarian mass in pediatric surgery. Journal Article links:  Madenci AL, Vandewalle RJ, Dieffenbach BV, Laufer MR, Boyd TK, Voss SD, et al. Multicenter pre-operative assessment of pediatric ovarian malignancy. J Pediatr Surg 2019;54(9):1921-5. https://pubmed.ncbi.nlm.nih.gov/30867096/ Dasgupta R, Renaud E, Goldin AB, Baird R, Cameron DB, Arnold MA, et al. Ovarian torsion in pediatric and adolescent patients: A systematic review. J Pediatr Surg 2018;53(7):1387-91. https://pubmed.ncbi.nlm.nih.gov/29153467/

Trisomy 13 & 18 Ethical Considerations with Dr. Paul Mann PARTICIPANTS: Paul Mann, MD Zachary Hodges, MD About Our Guest: Dr. Paul Mann is an Associate Professor of Pediatrics, Chief of the Division of Neonatology and practicing neonatologist at the Medical College of Georgia. He also is the Director of Clinical Ethics for the Augusta University Center for Bioethics and Health Policy. Free CME Credit: https://mcg.cloud-cme.com/course/courseoverview?P=0&EID=7772 Learning Objectives: By the end of listening to this episode, learners should be able to: Recognize aneuploidies as a common cause of genetic abnormalities in pregnancy. Recognize the historically pessimistic counseling given to families of children with trisomy 13 and 18 and how this might continue to influence our counseling today. Recall how most babies are prenatally diagnosed with trisomy 13 and 18. Describe the life-limiting malformations associated with trisomy 13 and 18. Recognize the recent improvement in prognosis of children with trisomy 13 and 18 as they are being selectively offered more intensive and surgical care. Sensitively counsel families about the general prognosis of newborns with trisomy 13 and 18 while avoiding inaccurate and problematic language such as “lethal and incompatible with life.”        Thank you for listening to this episode from the Department of Pediatrics at the Medical College of Georgia. If you have any comments, suggestions, or feedback- you can email us at mcgpediatricpodcast@augusta.edu. Remember that all content during this episode is intended for informational and educational purposes only. It should not be used as medical advice to diagnose or treat any particular patient. Clinical vignette cases presented are based on hypothetical patient scenarios. We look forward to speaking to you on our next episode of the MCG Pediatric Podcast.     Peer Reviewers: Amy Thompson, MD & MCG Pediatric Podcast Committee   References: Kett JC. Who Is the Next "Baby Doe?" From Trisomy 21 to Trisomy 13 and 18 and Beyond. Pediatrics. 2020;146(Suppl 1):S9-S12. doi:10.1542/peds.2020-0818D American College of Obstetricians and Gynecologists' Committee on Practice Bulletins—Obstetrics; Committee on Genetics; Society for Maternal–Fetal Medicine. Practice Bulletin No. 162: Prenatal Diagnostic Testing for Genetic Disorders. Obstet Gynecol. 2016;127(5):e108-e122. doi:10.1097/AOG.0000000000001405 Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs. Stamford, Conn: Appleton & Lange, 1999. Print. McCaffrey MJ. Trisomy 13 and 18: Selecting the road previously not taken. Am J Med Genet C Semin Med Genet. 2016;172(3):251-256. doi:10.1002/ajmg.c.31512 Bajinting A, Munoz-Abraham AS, Osei H, Kirby AJ, Greenspon J, Villalona GA. To operate or not to operate? Assessing NSQIP surgical outcomes in trisomy 18 patients [published online ahead of print, 2020 Jun 5]. J Pediatr Surg. 2020;S0022-3468(20)30369-9. doi:10.1016/j.jpedsurg.2020.05.037 Neubauer K, Boss RD. Ethical considerations for cardiac surgical interventions in children with trisomy 13 and trisomy 18. Am J Med Genet C Semin Med Genet. 2020;184(1):187-191. doi:10.1002/ajmg.c.31767 Wightman A, Kett J, Campelia G, Wilfond BS. The Relational Potential Standard: Rethinking the Ethical Justification for Life-Sustaining Treatment for Children with Profound Cognitive Disabilities. Hastings Cent Rep. 2019;49(3):18-25. doi:10.1002/hast.1003 Nelson KE, Rosella LC, Mahant S, Guttmann A. Survival and Surgical Interventions for Children With Trisomy 13 and 18 [published correction appears in JAMA. 2017 May 2;317(17 ):1803]. JAMA. 2016;316(4):420-428. doi:10.1001/jama.2016.9819

The differential diagnosis is long... You need an approach.   The Rule of 3s: 3 minutes -- Traumatic 3 days -- Inflammatory 3 months -- Neoplastic 3 years -- Congenital   3 Minutes?  Traumatic   3 Days?  Inflammatory [caption id="attachment_1777" align="alignnone" width="262"] Cervical Node Chain; Lymphadenopathy[/caption] [caption id="attachment_1773" align="alignnone" width="298"] Bacterial Lymphadenitis[/caption] [caption id="attachment_1772" align="alignnone" width="300"] Bacterial lymphadenitis with small abscess[/caption] [caption id="attachment_1771" align="alignnone" width="300"] Large Abscess[/caption]   3 Months?  Neoplastic   3 Years?  Congenital [caption id="attachment_1784" align="alignnone" width="300"] Thyroglossal Duct Cyst[/caption] [caption id="attachment_1783" align="alignnone" width="300"] Thyroglossal Duct Cyst[/caption] [caption id="attachment_1776" align="alignnone" width="278"] Branchial Cleft Cyst[/caption] [caption id="attachment_1775" align="alignnone" width="263"] Branchial Cleft Cyst[/caption] [caption id="attachment_1774" align="alignnone" width="233"] Branchial Cleft Cyst[/caption] [caption id="attachment_1779" align="alignnone" width="300"] Cystic Hygroma[/caption]   [caption id="attachment_1778" align="alignnone" width="235"]  Cystic Hygroma[/caption]   Selected References Enepekides DJ. Management of congenital anomalies of the neck. Facial Plast Surg Clin North Am 2001; 9:131. Lin ST, Tseng FY, Hsu CJ, et al. Thyroglossal duct cyst: a comparison between children and adults. Am J Otolaryngol 2008; 29:83. Mandell DL. Head and neck anomalies related to the branchial apparatus. Otolaryngol Clin North Am 2000; 33:1309. Marler JJ, Mulliken JB. Current management of hemangiomas and vascular malformations. Clin Plast Surg 2005; 32:99. Silverman, J. F., Gurley, A. M., Holbrook, C. T., Joshi, V. V. (1991) Pediatric fine needle aspiration biopsy. American Journal of Clinical Pathology 95: 653–659 Sonnino RE, Spigland N, Laberge JM, Desjardins J, Guttman FM. Unusual patterns of congenital neck masses in children. J Pediatr Surg. 1989 Oct;24(10):966-9.

Abdominal pain is common; so are strongly held myths and legends about what is concerning, and what is not.   One of our largest responsibilities in the Emergency Department is sorting out benign from surgical or medical causes of abdominal pain.  Morbidity and mortality varies by age and condition.   Abdominal Surgical Emergencies in Children: A Relative Timeline General Advice Neonate (birth to one month) Necrotizing Enterocolitis Pneumatosis Intestinalis. Essentials: Typically presents in 1st week of life (case reports to 6 months in chronically ill children) Extend suspicion longer in NICU graduates Up to 10% of all cases of necrotizing enterocolitis are in full-term children Pathophysiology is unknown, but likely a translocation of bacteria Diagnosis: Feeding intolerance, abdominal distention Abdominal XR: pneumatosis intestinalis Management: IV access, NG tube, broad-spectrum antibiotics, surgery consult, ICU admission Intestinal Malrotation with Volvulus Essentials: Corkscrew Sign in Malrotation with Volvulus Bilious vomiting (80-100%) in the 1st month; especially in the 1st week May look well initially, then rapidly present in shock Ladd’s bands: abnormally high tethering of cecum to abdominal wall; peristalsis, volvulus, ischemia Diagnosis: History of bilious emesis is sufficient to involve surgeons Upper GI series: corkscrew appearance US (if ordered) may show abnormal orientation of and/or flow to superior mesenteric artery and vein Management: Stat surgical consult IV access, resuscitation, NG tube to decompress (bowel wall perfusion at risk, distention worsens) Hirschprung Disease Essentials: Problem in migration of neural crest cells Aganglionic colon (80% rectosigmoid; 15-20% proximal to sigmoid; 5% total colonic aganglionosis) colon (known as short-segment disease) Poor to no peristalsis: constipation, perforation, and/or sepsis Diagnosis: May be diagnosed early as “failure to pass meconium in 1st 48 hours” In ED, presents as either bowel obstruction or enterocolitis Contrast enema Beware of the toxic megacolon (vomiting, distention, sepsis) Management: Resuscitation, antibiotics, NG tube decompression, surgical consultation; stable patients may need rectal biopsy for confirmation Staged surgery (abdominoperineal pull-through with diverting colostomy, subsequent anastomosis) versus one-stage repair. Infant and Toddler (1 month to 2 years) Pyloric Stenosis Essentials: Hypertrophy of pyloric sphincter; genetic, environmental, exposure factorsString Sign in Pyloric Stenosis. Diagnosis: Hungry, hungry, not-so-hippos; they want to eat all of the time, but cannot keep things down Poor weight gain (less than 20-30 g/day) US: “π–loric stenosis” (3.14); pylorus dimensions > 3 mm x 14 mm UGI: “string sign” Management: Trial of medical treatment with oral atropine via NGT (muscarinic effects decrease pyloric tone) Ramstedt pyloromyotomy (definitive) Intussusception Essentials: Majority (90%) ileocolic; no pathological lead point Small minority (4%) ileoileocolic due to lead point: Meckel’s diverticulum, polyp, Peyer’s patches, Henoch-Schönlein purpura (intestinal hematoma) Diagnosis: Target Sign (Donut Sign). Ultrasound sensitivity and specificity near 100% in experienced hands Abdominal XR may show non-specific signs; used mainly to screen for perforation before reduction Management: Hydrostatic enema: contrast (barium or water-soluble contrast with fluoroscopy) or saline (with ultrasound) Air-contrast enema: air or carbon dioxide (with either fluoroscopy or ultrasound); higher risk for perforation than hydrostatic (1% risk), but generally safer than perforation from contrast Consider involving surgical service early (precaution before reduction) Traditional disposition is admission; controversial: home discharge from ED Young Child and Older (2 years and up) Appendicitis Essentials: Appendicitis occurs in all ages, but rarer in infants. Infants do not have fecalith; rather they have some other anatomic or congenital condition.  More common in school-aged children (5-12 years) and adolescents Younger children present atypically, more likely to have perforated when diagnosed. Diagnosis: Non-specific signs and symptoms Often have abdominal pain first; vomiting comes later Location/orientation of appendix varies Appendicitis scores vary in their performance Respect fever and abdominal pain   Management: Traditional: surgical On the horizon: identification of low-risk children who may benefit from trial of antibiotics If perforated, interval appendectomy (IV antibiotics via PICC for 4-6 weeks, then surgery) Obstruction SBO. Incarcerated Inguinal Hernia. Essentials: Same pathophysiology and epidemiology as adults: “ABC” – adhesions, “bulges” (hernias), and cancer. Diagnosis: Obstruction is a sign of another condition. Look for cause of obstruction: surgical versus medical Abdominal XR in low pre-test probability CT abdomen/pelvis for moderate-to-high risk; confirmation and/or surgical planning Management: Treat underlying cause NG tube to low intermittent wall suction Admission, fluid management, serial examinations   Take these pearls home: Consider surgical pathology early in encounter Resuscitate while you investigate Have a low threshold for imaging and/or consultation, especially in preverbal children   Selected References Necrotizing Enterocolitis Neu J, Walker A. Necrotizing Enterocolitis. N Eng J Med. 2011; 364(3):255-264. Niño DF et al. Necrotizing enterocolitis: new insights into pathogenesis and mechanisms. Nature. 2016; 13:590-600. Walsh MC et al. Necrotizing Enterocolitis: A Practitioner’s Perspective. Pediatr Rev. 1988; 9(7):219-226. Malrotation with Midgut Volvulus Applegate KE. Intestinal Malrotation in Children: A Problem-Solving Approach to the Upper Gastrointestinal Series. Radiographics. 2006; 26:1485-1500. Kapfer SA, Rappold JF. Intestinal Malrotation – Not Just the Pediatric Surgeon’s Problem. J Am Coll Surg. 2004; 199(4):628-635. Lee HC et al. Intestinal Malrotation and Catastrophic Volvulus in Infancy. J Emerg Med. 2012; 43(1):49-51. Martin V, Shaw-Smith C. Review of genetic factors in intestinal malrotation. Pediatr Surg Int. 2010; 26:769-781. Nehra D, Goldstein AM. Intestinal malrotation: Varied clinical presentation from infancy through adulthood. Surgery. 2010; 149(3):386-391. Hirschprung Disease Amiel J, Sproat-Emison E, Garcia-Barcelo M, et al. Hirschsprung disease, associated syndromes and genetics: a review. J Med Genet 2008; 45:1. Arshad A, Powell C, Tighe MP. Hirschsprung's disease. BMJ 2012; 345:e5521. Aworanti OM, McDowell DT, Martin IM, Quinn F. Does Functional Outcome Improve with Time Postsurgery for Hirschsprung Disease? Eur J Pediatr Surg 2016; 26:192. Clark DA. Times of first void and first stool in 500 newborns. Pediatrics 1977; 60:457. Dasgupta R, Langer JC. Evaluation and management of persistent problems after surgery for Hirschsprung disease in a child. J Pediatr Gastroenterol Nutr 2008; 46:13. De Lorijn F, Reitsma JB, Voskuijl WP, et al. Diagnosis of Hirschsprung's disease: a prospective, comparative accuracy study of common tests. J Pediatr 2005; 146:787. Doig CM. Hirschsprung's disease and mimicking conditions. Dig Dis 1994; 12:106. Khan AR, Vujanic GM, Huddart S. The constipated child: how likely is Hirschsprung's disease? Pediatr Surg Int 2003; 19:439. Singh SJ, Croaker GD, Manglick P, et al. Hirschsprung's disease: the Australian Paediatric Surveillance Unit's experience. Pediatr Surg Int 2003; 19:247. Suita S, Taguchi T, Ieiri S, Nakatsuji T. Hirschsprung's disease in Japan: analysis of 3852 patients based on a nationwide survey in 30 years. J Pediatr Surg 2005; 40:197. Sulkowski JP, Cooper JN, Congeni A, et al. Single-stage versus multi-stage pull-through for Hirschsprung's disease: practice trends and outcomes in infants. J Pediatr Surg 2014; 49:1619. Pyloric Stenosis Aspelund G, Langer JC. Current management of hypertrophic pyloric stenosis. Semin Pedaitr Surg. 2007; 16:27-33. Dias SC et al. Hypertrophic pyloric stenosis: tips and tricks for ultrasound diagnosis. Insights Imaging. 2012; 3:247-250. Kawahara H et al. Medical treatment of infantile hypertrophic pyloric stenosis: should we always slice the olive? J Pediatr Surg. 2005; 40:1848-1851. Mack HC. Adult Hypertrophic Pyloric Stenosis. Arch Inter Med. 1959; 104:78-83. Meissner PE et al. Conservative treatment of infantile hypertrophic pyloric stenosis with intravenous atropine sulfate does not replace pyloromyotomy. Pediatr Surg Int. 2006; 22:1021-1024. Mercer AE, Phillips R. Can a conservative approach to the treatment of hypertrophic pyloric stenosis with atropine be considered a real alternative to pyloromyotomy? Arch Dis Child. 2013; 95(6): 474-477. Pandya S, Heiss K, Pyloric Stenosis in Pediatric Surgery.Surg Clin N Am. 2012; 92:527-39. Peters B et al. Advances in infantile hypertrophic pyloric stenosis. Expert Rev Gastroenterol Hepatol. 2014; 8(5):533-541. Intussusception Apelt N et al. Laparoscopic treatment of intussusception in children: A systematic review. J Pediatr Surg. 2013; 48:1789-1793. Applegate KE. Intussusception in Children: Imaging Choices. Semin Roentgenol. 2008; 15-21. Bartocci M et al. Intussusception in childhood: role of sonography on diagnosis and treatment. J Ultrasound. 2015; 18 Gilmore AW et al. Management of childhood intussusception after reductiion by enema. Am J Emerg Med. 2011; 29:1136-1140.:205-211. Chien M et al. Management of the child after enema-reduced intussusception: hospital or home? J Emerg Med. 2013; 44(1):53-57. Cochran AA et al. Intussusception in traditional pediatric, nontraditional pediatric, and adult patients. Am J Emerg Med. 2011; 523-527. Loukas M et al. Intussusception: An Anatomical Perspective With Review of the Literature. Clin Anatomy. 2011; 24: 552-561. Mendez D et al. The diagnostic accuracy of an abdominal radiograph with signs and symptoms of intussusception. Am J Emerg Med. 2012; 30:426-431. Whitehouse et al. Is it safe to discharge intussusception patients after successful hydrostatic reduction? J Pediatr Surg. 2010; 45:1182-1186. Appendicitis Amin P, Chang D. Management of Complicated Appendicitis in the Pediatrc Population: When Surgery Doesn’t Cut it. Semin Intervent Radiol. 2012; 29:231-236 Blakely ML et al. Early vs Interval Appendectomy for Children With Perforated Appendicitis. Arch Surg. 2011; 146(6):660-665. Bundy DG et al. Does This Child Have Appendicitis? JAMA. 2007; 298(4):438-451. Cohen B et al. The non-diagnostic ultrasound in appendicitis: is a non-visualized appendix the same as a negative study? J Pediatr Surg. 2015 Jun;50(6):923-7 Herliczek TW et al. Utility of MRI After Inconclusive Ultrasound in Pediatric Patients with Suspected Appendicitis. AJT. 2013; 200:969-973. Janitz et al. Ultrasound Evaluation for Appendicitis. J Am Osteopath Coll Radiol. 2016; 5(1):5-12. Kanona H et al. Stump Appendicitis: A Review. Int J Surg. 2012; 10:4255-428. Kao LS et al. Antibiotics vs Appendectomy for Uncomplicated Acute Appendicitis. Evid Based Rev Surg. 2013;216(3):501-505. Petroianu A. Diagnosis of acute appendicitis. Int J Surg. 2012; 10:115-119. Mazeh H et al. Tip appendicitis: clinical implications and management. Amer J Surg. 2009; 197:211-215. Puig S et al. Imaging of Appendicitis in Children and Adolescents. Semin Roentgenol. 2008; 22-28. Schizas AMP, Williams AB. Management of complex appendicitis. Surgery. 2010; 28(11):544-548. Shogilev DJ et al. Diagnosing Appendicitis: Evidence-Based Review. West J Emerg Med. 2014; 15(4):859-871. Wray CJ et al. Acute Appendicitis: Controversies in Diagnosis and Management. Current Problems in Surgery. 2013; 50:54-86 Intestinal Obstruction Babl FE et al. Does nebulized lidocaine reduce the pain and distress of nasogastric tube insertion in young children? A randomized, double-blind, placebo-controlled trial. Pediatrics. 2009 Jun;123(6):1548-55 Chinn WM, Zavala DC, Ambre J. Plasma levels of lidocaine following nebulized aerosol administration. Chest 1977;71(3):346-8. Cullen L et al. Nebulized lidocaine decreases the discomfort of nasogastric tube insertion: a randomized, double-blind trial. Ann Emerg Med. 2004 Aug;44(2):131-7. Gangopadhyay AN, Wardhan H. Intestinal obstruction in children in India. Pediatr Surg Int. 1989; 4:84-87. Hajivassiliou CA. Intestinal Obstruction in Neonatal/Pediatric Surgery. Semin Pediatr Surg. 2003; 12(4):241-253. Hazra NK et al. Acute Intestinal Obstruction in children: Experience in a Tertiary Care Hospital. Am J Pub Health Res. 2015; 3(5):53-56. Kuo YW et al. Reducing the pain of nasogastric tube intubation with nebulized and atomized lidocaine: a systematic review and meta-analysis. J Pain Symptom Manage. 2010 Oct;40(4):613-20.  . Pediatric Surgery Irish MS et al. The Approach to Common Abdominal Diagnoses in Infants and Children. Pedaitr Clin N Am. 1998; 45(4):729-770. Louie JP. Essential Diagnosis of Abdominal Emergencies in the First Year of Life. Emerg Med Clin N Am. 2007; 25:1009-1040. McCullough M, Sharieff GQ. Abdominal surgical emergencies in infants and young children. Emerg Med Clin N Am. 2003; 21:909-935. Pepper VK et al. Diagnosis and Management of Pediatric Appendicitis, Intussusception, and Meckel Diverticulum. Surg Clin N Am. 2012   This post and podcast are dedicated to Mr Ross Fisher for his passion and spirit of collaboration in all things #FOAMed.  Thank you, sir!

When you give only after you're asked, you've waited too long. – John Mason First, learn to bag Place a towel roll under the scapulae to align oral, pharyngeal, and tracheal axes: Karsli C. Can J Anesth. 2015. Use airway adjuncts such as the oropharyngeal airway or a nasal trumpet. Use the two-hand ventilation technique whenever possible:   (See Adventures in RSI for more)     Supraglottic Airways: for difficult bag-valve-mask ventilation or a difficult airway (details in audio) LMA Classic Pros: Best studied; sizes for all ages Cons: Cannot intubate through aperture   LMA Supreme Pros: Better ergonomics with updated design; bite bloc; port for decompression Cons: Cannot pass appropriate-sized ETT through tube   King Laryngeal Tube Pros: Little training needed; high success rate; single inflation port Cons: Flexion of tube can impede ventilation or cause leaks; only sized down to 12 kg (not for infants and most toddlers)   Air-Q Pros: Easy to place; can intubate through aperture Cons: Not for neonates less than 4 kg   iGel Pros: Molds more accurately to supraglottis; no need to inflate; good seal pressures Cons: Cannot intubate through (without fiberoscopy)   Summary • If you can bag the patient, you're winning. • If you have difficulty bagging, or anticipate or encounter a difficult airway, then don't forget your friend the supraglottic airway (SGA). • Ego is the enemy of safety: SGAs are simple, fast, and reliable. • Just do it.   References Ahn EJ et al. Comparative Efficacy of the Air-Q Intubating Laryngeal Airway during General Anesthesia in Pediatric Patients: A Systematic Review and Meta-Analysis. Biomed Res Int. 2016;2016:6406391. Black AE, Flynn PE, Smith HL, Thomas ML, Wilkinson KA; Association of Pediatric Anaesthetists of Great Britain and Ireland. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth. 2015 Apr;25(4):346-62. Byars DV et al. Comparison of direct laryngoscopy to Pediatric King LT-D in simulated airways. Pediatr Emerg Care. 2012 Aug;28(8):750-2.  Carlson JN, Mayrose J, Wang HE. How much force is required to dislodge an alternate airway? Prehosp Emerg Care. 2010 Jan-Mar;14(1):31-5. Diggs LA, Yusuf JE, De Leo G. An update on out-of-hospital airway management practices in the United States. Resuscitation. 2014 Jul;85(7):885-92. Ehrlich PF et al. Endotracheal intubations in rural pediatric trauma patients. J Pediatr Surg. 2004 Sep;39(9):1376-80. Hernandez MR, Klock PA Jr, Ovassapian A. Evolution of the extraglottic airway: a review of its history, applications, and practical tips for success. Anesth Analg. 2012 Feb;114(2):349-68.  Huang AS, Hajduk J, Jagannathan N. Advances in supraglottic airway devices for the management of difficult airways in children. Expert Rev Med Devices. 2016;13(2):157-69. Jagannathan N, Wong DT. Successful tracheal intubation through an intubating laryngeal airway in pediatric patients with airway hemorrhage. J Emerg Med. 2011 Oct;41(4):369-73.  Jagannathan N et al. Elective use of supraglottic airway devices for primary airway management in children with difficult airways. Br J Anaesth. 2014 Apr;112(4):742-8. Jagannathan N, Ramsey MA, White MC, Sohn L. An update on newer pediatric supraglottic airways with recommendations for clinical use. Paediatr Anaesth. 2015 Apr;25(4):334-45. Karsli C. Managing the challenging pediatric airway: Continuing Professional Development. Can J Anaesth. 2015 Sep;62(9):1000-16. Luce V et al. Supraglottic Airway Devices vs Tracheal Intubation in Children: A Quantitative Meta-Analysis of Respiratory Complications. Paediatr Anaesth 24 (10), 1088-1098. Nicholson A et al. Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients. Cochrane Database Syst Rev. 2013 Sep 9;(9):CD010105. Ostermayer DG, Gausche-Hill M. Supraglottic airways: the history and current state of prehospital airway adjuncts. Prehosp Emerg Care. 2014 Jan-Mar;18(1):106-15.  Rosenberg MB, Phero JC, Becker DE. Essentials of airway management, oxygenation, and ventilation: part 2: advanced airway devices: supraglottic airways. Anesth Prog. 2014 Fall;61(3):113-8.  Schmölzer GM, Agarwal M, Kamlin CO, Davis PG. Supraglottic airway devices during neonatal resuscitation: an historical perspective, systematic review and meta-analysis of available clinical trials. Resuscitation. 2013 Jun;84(6):722-30. Sinha R, Chandralekha, Ray BR. Evaluation of air-Q™ intubating laryngeal airway as a conduit for tracheal intubation in infants--a pilot study. Paediatr Anaesth. 2012 Feb;22(2):156-60. Timmermann A. Supraglottic airways in difficult airway management: successes, failures, use and misuse. Anaesthesia. 2011 Dec;66 Suppl 2:45-56. Timmermann A, Bergner UA, Russo SG. Laryngeal mask airway indications: new frontiers for second-generation supraglottic airways. Curr Opin Anaesthesiol. 2015 Dec;28(6):717-26.   Supraglottic Airway on WikEM   This post and podcast are dedicated to Tim Leeuwenburg, MBBS FRACGP FACRRM DRANZCOG DipANAES and Rich Levitan, MD, FACEP for keeping our minds and our patients' airways -- open.  You make us better doctors.  Thank you. Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP Pediatric; Emergency Medicine; Pediatric Emergency Medicine; Podcast; Pediatric Podcast; Emergency Medicine Podcast; Horeczko; Harbor-UCLA; Presentation Skills; #FOAMed #FOAMped #MedEd

A 5-year-old boy was playing with his older brother in front of their home when he was struck by a car. He sustained a femur fracture, splenic laceration, and blunt head trauma – the so-called Waddell’s triad. On arrival, he was in compensated shock, with tachycardia. He decompensates and needs blood. How do we manage his hemodynamics and when do we perform massive transfusion? Pediatric Massive Transfusion 40 mL/kg of blood products given at any time within the first 24 hours. Adolescents and Adult Massive Transfusion 6-8 units of packed red blood cells (PRBCs) Adults have about 5 L of circulating blood. Not including plasma, one could replace all circulating erythrocytes with about 10 units of PRBCS The best ratio of PRBCs:Plasma:Platelets is unknown, but consensus is 1:1:1. 1 unit of PRBCS is typically 300 mL of volume. The typical initial transfusion of PRBCs in children is 10 mL/kg. Massive transfusion in children is defined as 40 mL/kg of any blood product. Once you start to give a child with major trauma the second 10 mL/kg dose of PRBCs – start thinking about other blood components, and ask yourself whether you should initiate your massive transfusion protocol. The goal is to have the products ready to use in the case of the dynamic trauma patient. The Thromboelastogram (TEG) Direct measures the four components of clot formation. When there is endolethial damage and bleeding, the sequence that your body takes to address it is as follows:  Platelets migrate and form a plug Clotting factors aggregate and reinforce the platelets Fibrin arrives an acts like glue Other cells migrate and support the clot. R time – reaction time – the initial line in the tracing that shows time to beginning of clot formation. Treated with platelets K factor – kinetics of the clot –how much the clot allows the pin to move, or the amplitude. Treated with cryoprecipitate Alpha angle – the slope between the R and K measurements – reflects how quickly the fibrin glue is working. Treated with cryoprecipitate Ma – maximum amplitude – reflects the overall strength of the clot. Treated with platelets LY30 – the clot lysis at 30 min – is the decrease in strength of the clot’s amplitude at 30 min. Treated with an antifibrinolytics (tranexamic acid) Shape Recognition Red wine glass: a normal tracing with a normal reaction time and a normal amplitude. That patient just needs support and monitoring. Champagne glass: a coagulopathic TEG tracing – thinned out, with less amplitude. This patient needs specific blood products. Puffer fish or blob: a hyperfibrinolytic tracing. That patient will needs clot-stablizer. TEG – like the FAST – can be repeated as the clinical picture changes. The Trauma Death Spiral Lethal triad of hypothermia, acidosis, and coagulopathy. Keep the patient perfused and warm. Each unit of PRBCs contains 3 g citrate, which binds ionized calcium, causing hypotension. In massive transfusion, give 20 mg/kg of calcium chloride, up to 2 g, over 15 minutes. Calcium chloride is preferred, as it is ionically readily available – just use a larger-bore IV and watch for infiltration. Calcium gluconate could be used, but it requires metabolism into a bioavailable source of calcium. Prothrombin complex concentrate (PCC) Prothrombin complex concentrate (PCC) is derived from pooled human plasma and contains 25-30 times the concentration of clotting factors as FFP. Four-factor PCCs contain factors II, VII, IX and X, while 3-factor PCCs contain little or no factor VII. The typical dose of PCC is 20-50 units/kg In the severely hemorrhaging patient – you don’t have time to wait for the other blood products to thaw – PCC is a powder that is reconstituted instantly at the bedside. Tranexamic acid (TXA) Tranexamic acid (TXA), is an anti-fibrinolytic agent that functions by stopping the activation of plasminogen to plasmin, and the degradation of fibrin. The Clinical Randomisation of an Antifibrinolytic in Significant Hemorrhage (CRASH-2) investigators revealed a significant decrease in death secondary to bleeding when TXA was administered early following trauma. Based on the adult literature, one guideline is to give 15 mg/kg loading dose of TXA with a max 1 g over 10 minutes followed by 2 mg/kg/h for at least 8 h or until bleeding stops. Resuscitative Pearls Our goal here is damage control. Apply pressure whenever possible. Otherwise, resuscitate, identify the bleeding source, and slow or stop the bleeding with blood products or surgery. How Children are Different in Trauma In adults, we speak of “permissive hypotension” (also called “balanced resuscitation” or “damage control resuscitation”). The idea is that if we bring the adult patient’s blood pressure up to normal, we may be promoting clot rupture. To avoid this, we target a MAP of 65 and look for clinical signs of sufficient perfusion. Adults tolerate hypotension relatively well, and is sufficient until we send them to the OR or interventional radiology suite. In children, this is simply not the case. Hypotension in children is a sign of pre-arrest. Remember, they compensate with an increased systemic vascular resistance and tachycardia to maintain blood pressure. We should not allow children to become hypotensive – severe tachycardia alone should prompt us to resuscitate. In other words, permissive hypotension is not permissible for children. FAST is not sensitive enough to rule-out abdominal trauma. Fox et al in Academic Emergency Medicine found a sensitivity of 52%; with a 95% confidence interval [CI] = 31% to 73%. Often children even with high-grade splenic and liver lacerations can be managed non-operatively. If they are supported adequately, they are observed in the ICU and can avoid surgery in many cases. Unfortunately, a negative FAST cannot help with detecting or grading the laceration for non-operative management. In other words, feel free to use ultrasound – especially for things that we in the ED will react to and intervene on – but CT may help to manage the traumatized child non-operatively. General Guideline for Imaging in Pediatric Trauma CT Head and Neck, non-contrast: in concerning mechanisms of injury, patients that are difficult to assess (especially those under 3 months), those with a GCS of 13 or lower. CT Chest, IV contrast: for suspicion of vascular injury that needs exploration, especially in penetrating trauma. Otherwise, chest xray will tell you everything you need to know in children – especially in blunt trauma. Hemo or pneumothoraces are readily picked up by US or CXR. Rib fractures on CXR predict pulmonary contusions. If you are concerned about great vessel injury, then CT Chest may be helpful; otherwise consider omitting it. CT Abdomen and Pelvis, IV contrast: helpful in grading splenic and liver lacerations with goal to manage non-operatively. Abdominal tenderness to palpation, significant bruising, or a seat belt sign are concerning and would generally warrant a CT. Also, consider in liver function test abnormalities, or hematuria. Extremity injuries: in general can be evaluated with physical exam and plain films. However, some injuries in high-risk anatomically complex areas such as the hand and wrist, tibial plateau, and midfoot may be missed by plain films, and CT may be helpful here. Remember: you can help to mitigate post-traumatic stress and risk for adult healthcare aversion. Summary Massive transfusion in children is at 40 mL/kg of total blood products. Think about it if you are giving your second transfusion to the traumatized child. Do everything you can to support perfusion and avoid the death spiral of hypothermia, coagulopathy, and acidosis. Keep the child perfused with blood as needed, correct coagulopathy, avoid too much crystalloid, and make sure to use the least high-tech of all of these interventions – keep him dry and covered with warm blankets. Do a careful physical exam, and use CT selectively with an end-point in mind – the default is not the pan-scan – evaluate possible injuries depending on your suspicions from history, physical, and lab tests. Become familiar with the relatively new modalities in trauma such as TXA, cryoprecipitate and the emerging technology of thromboelestogram – red wine is good for you, champagne is weak, and a puffer fish is trouble. Selected References Dehmer JJ, Adamson WT. Massive transfusion and blood product use in the pediatric trauma patient. Semin Pediatr Surg. 2010 Nov;19(4):286-91. doi: 10.1053/j.sempedsurg.2010.07.002. Fox JC, Boysen M, Gharahbaghian L, Cusick S, Ahmed SS, Anderson CL, Lekawa M, Langdorf MI. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med. 2011 May;18(5):477-82. Harvey V, Perrone J, Kim P. Does the use of tranexamic acid improve trauma mortality? Ann Emerg Med. 2014 Apr;63(4):460-2. Holscher CM, Faulk LW, Moore EE, Cothren Burlew C, Moore HB, Stewart CL, Pieracci FM, Barnett CC, Bensard DD. Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk. J Surg Res. 2013 Sep;184(1):352-7. Nosanov L, Inaba K, Okoye O, Resnick S, Upperman J, Shulman I, Rhee P, Demetriades D. The impact of blood product ratios in massively transfused pediatric trauma patients. Am J Surg. 2013 Nov;206(5):655-60. Ryan ML, Van Haren RM, Thorson CM, Andrews DM, Perez EA, Neville HL, Sola JE, Proctor KG. Trauma induced hypercoagulablity in pediatric patients. J Pediatr Surg. 2014 Aug;49(8):1295-9. Scaife ER, Rollins MD, Barnhart DC, Downey EC, Black RE, Meyers RL, Stevens MH, Gordon S, Prince JS, Battaglia D, Fenton SJ, Plumb J, Metzger RR. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. J Pediatr Surg. 2013 Jun;48(6):1377-83. This post and podcast are dedicated to Larry Mellick, MS, MD, FAAP, FACEP. Thank you for your dedication to medical education, and sharing your warm bedside manner, extensive knowledge and talents, and your patient interactions with the world. Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP

Traumatized children need your full attention. Protocols work well for adults, but trauma in children requires that we exercise our clinical muscles just a bit more.   Two main reasons:  Children have specific injury patterns  Their physiologic response to trauma is unique.   Crash course in pediatric anatomy and physiology in trauma When you think of trauma in children, think of Charlie Brown. Large head, no neck, his chest and abdomen form an underdeveloped, amorphous shape. Alternatively, think of children as apples – they are rounder than they are tall, with a large increased surface area. Apples don’t have a hard shell or thick rind to protect them. If you drop them, you may not see any evidence of damage to the outside, but there can be considerable bruising just under the surface. A child has thin skin, less subcutaneous deposits than an adult, and a non-calcified, pliable thorax that deforms more than it protects or shields. The child’s abdominal muscles are not yet developed. There is less peritoneal fat to cushion a blow, and so traumatic forces transmit readily into internal organs, often without external bruising. The child’s large surface area also causes him to dissipate heat more quickly. He may be wet from urine or blood, and in a major trauma, this faster cool-down predisposes him to coagulopathy. Case A 5-year-old boy who was playing with his older brother in front of their home when the ball rolled into the street. He ran after it, and was struck by a sedan going approximately 30 mph. This is the so-called Wadell’s triad that occurs in a collision of auto versus pedestrian or auto versus bicycle. The initial impact is the greatest, and will vary depending on the child’s height and what part of his body reaches up to the bumper of the car. Depending on the height of the child and the height of the car, the initial impact will cause a femur fracture, a pelvic fracture, or direct abdominal trauma. The second impact happens as the child is flung onto the grill or the hood of the car, causing usually thoracic trauma. The third impact can be the coup de grace – to add insult to major injury, the child is then propelled forward, worsening the two previous impacts’ injuries and adding a third – severe blunt head trauma. Intubation Pearl #1: If your patient has any subtle change in mental status, intubate early. In pediatric trauma, we need to be proactive. Hypoxia is our enemy. Intubation Pearl #2: Thankfully cervical spine injuries in children are uncommon, and when they do occur, they typically occur at the child’s fulcrum, which is at C2. Compare this with an adult’s injury pattern with our fulcrum at C7. Be careful and minimize manipulation of the cervical spine, but do what you must to visualize the chords and place the tube. Keep the neck midline, and realize that the child’s usual decrease respiratory reserve is even more affected by trauma. Preoxygenate and pass that tube quickly. Chest Tube Pearl #1: Chest tube sizing in pediatrics is straightforward if we remember that the traditional chest tube size is 4 x the ETT size. Chest Tube Pearl #2: Try using a pigtail catheter. Safety Triangle Lateral edge of the pectoral muscle Lateral edge of the latisimus dorsi Line along the fifth intercostal space at the level of the nipple. It’s roughly where you would put on a generous dose of deodorant. Insertion here minimizes the risk of damage to nerves, vessels and organs. Resuscitative Thoracotomy in Children In a 40-year review of ED thoracotomy, Moore et al. analyzed 1,691 patients who received ED thoracotomy. Overall all-cause adult survival was 6.1%. In children ? 15 years of age, overall all-cause survival was considerably less, at 3.4%. In a large case series and review of the literature for pediatric ED thoracotomy, Allen et al. found a survival rate in penetrating trauma of 10.2%, with a much lower survival rate in blunt pediatric arrest, at 1.6%. Adolescents had more penetrating injuries, and younger children had more blunt trauma. To synthesize, the rarity of ED thoracotomy in children is due to the fact that: Traumatic full arrest in children is uncommon. It is most often blunt trauma. Blunt traumatic arrest in children is mostly non-survivable. REBOA If you have access to resuscitative endovascular balloon occlusion of the aorta or REBOA, this may be an option to temporize the child to get him to the relative control of the operating room. REBOA involves accessing the common femoral artery, passing a vascular sheath, floating a balloon catheter to the appropriate section of the aorta, and inflating the balloon to occlude blood flow. Brenner et al. described a case series of 6 patients from two Level I trauma centers. They used REBOA for refractory hemorrhagic shock due to either blunt or penetrating injury. After balloon occlusion, blood pressure improved sufficiently to take the patient either to interventional radiology or to the OR. Four patients lived, two died. The AORTA trial is underway to investigate its use in trauma. Summary: Children are like Charlie Brown – large head, no neck, amorphous, underdeveloped and unprotected thorax and abdomen. Or, if you like, they’re like, apples – they have a large surface area and are easily internally bruised, often without overt signs of external bruising. Chest tubes for children are very similar to the adult procedure – the traditional chest tube size is 4 x the child’s ETT size. Try to use smaller pigtail catheters, available in commercial kits, whenever possible. They’re easy, safe, and effective. Resuscitative thoracotomy is for penetrating trauma with signs of life wthin 10-15 minutes of arrival. Find the correctable surgical cause of the arrest. Resuscitative thoracotomy for blunt trauma has a dismal prognosis in children. Selected References Allen CJ, Valle EJ, Thorson CM, Hogan AR, Perez EA, Namias N, Zakrison TL, Neville HL, Sola JE. Pediatric emergency department thoracotomy: a large case series and systematic review. J Pediatr Surg. 2015 Jan;50(1):177-81. American College of Surgeons Committee on Trauma; American College of Emergency Physicians Pediatric Emergency Medicine Committee; National Association of Ems Physicians; American Academy of Pediatrics Committee on Pediatric Emergency Medicine, Fallat ME. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest. Pediatrics. 2014 Apr;133(4):e1104-16. Holscher CM, Faulk LW, Moore EE, Cothren Burlew C, Moore HB, Stewart CL, Pieracci FM, Barnett CC, Bensard DD. Chest computed tomography imaging for blunt pediatric trauma: not worth the radiation risk. J Surg Res. 2013 Sep;184(1):352-7. Moore HB, Moore EE, Bensard DD. Pediatric emergency department thoracotomy: A 40-year review. J Pediatr Surg. 2015 Oct 19. Scaife ER, Rollins MD, Barnhart DC, Downey EC, Black RE, Meyers RL, Stevens MH, Gordon S, Prince JS, Battaglia D, Fenton SJ, Plumb J, Metzger RR. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. J Pediatr Surg. 2013 Jun;48(6):1377-83. Stannard A, Eliason JL, Rasmussen TE. Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock. J Trauma. 2011 Dec;71(6):1869-72. Pediatric Trauma on WikEM   This post and podcast are dedicated to Dr Al Sacchetti, MD, FACEP. Thank you for promoting the emergency care of children and for spreading the message that you don’t need subspecialty training to take good care of acutely ill and injured children. Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP

Victims of electrical injuries present either in extremis or as the seeming well patient with insidious, developing disease. A targeted history usually gets you the information you need.     Four main things to find out: 1. Household or Industrial electricity? Household electricity uses alternating current, or AC.  Voltages across the world range anywhere from 100 to 240 V.  Here in North America, most outlets and appliances use 120 volts, which is the measure of electrical tension, or the potential difference in electrical charge. Cut-off between low voltage and high voltage is 1000 V. Industrial energy may be AC or direct current, DC.  DC current propels the victim -- think of this as a blast injury.  The same voltage in AC is three times as damaging as that voltage at DC, because AC causes muscle tetany, and prolonged contact time. 2. What was the likely pathway that current took? Did the current pass through the thorax?  -- Think dysrhythmias.  Through the head or neck?  -- Think damage to the CNS and risk for later central respiratory arrest; acoustic nerve damage; cataract formation.  Did the current pass along an extremity? -- Think compartment syndrome and rhabdomyolysis. 3. What was the contact time? The electrical charge meets resistance and converts to thermal energy, which causes tissue necrosis, increasing with the contact time.  Was your patient extricated?  Was there tetany?  Was he found in a pool of water or liquid?  Longer contact time correlates with extensive injuries that may only be apparent hours later. 4. Are there any associated injuries? Think of electrical injury as a trauma – major trauma rarely occurs in isolation.   Was the patient flung after contact?  Did he have a syncopal episode? -- Think precipitated dysrhythmia and fall.   Was there any chest pain?   -- Consider stress-induced ischemia.   Pearl: Patients may be confused initially or unable to localize symptoms because of CNS disruption.  Get collateral information, re-interview, and re-examine as needed.    Case 1: Toddler with an oral commissure burn An electrical burn to the angle of the mouth cauterizes superficial bleeding vessels, and hours later the wound becomes covered with a white layer of fibrin, surrounded by erythema.  Edema and thrombosis will continue, and at 24 hours there is typically a significant margin of tissue necrosis.  Most patients do well, and the burn heals by secondary intention.  The eschar will slough off in 1 to 2 weeks.  The labial artery is just deep to the burn, and as the eschar sloughs off, it can be exposed.  It’s a high-flow artery to the face, and if disrupted, the child may have significant bleeding and possibly hemorrhagic shock. These children need close wound care follow-up, and potentially outpatient coordination with Head and Neck Surgery and/or Plastic Surgery consultants. Precautionary advice:  take the moment to talk to parents about the risk, and show them how to apply pressure to the wound, pinching the inner and outer cheek together with the thumb and index finger until the child arrives to the hospital. Case 2: School-age child with knife versus electrical outlet A a “kissing burn” occurs when the electrical charge creates an arc and jumps to a more proximal portion of the extremity. The kissing burn typically occurs at flexor creases such as the wrist or the antecubital fossa.  There is often extensive underlying tissue damage even under the skin where it doesn’t appear to be involved.  Compartment syndrome and subsequent rhabdomyolysis and renal failure are the highest-risk complications. Case 3: Adolescent after a taser exposure Nitrogen capsules propel two barbs into the dermis, which deliver short bursts of energy; most patients have no harm from the electricity delivered. How to remove a dart:  The darts are typically 9 mm long, but the small barb is typically not buried very deep in the skin.  Hold the skin taught, use a hemostat to grasp the end as close to the skin as possible, align the dart perpendicularly to the skin, and pull quickly and firmly. If the patient can’t tolerate this or the barb appears particularly embedded, inject with local lidocaine and make a small superficial incision with an 11-blade scalpel just large enough to allow passage.   Ultrasound can be used to troubleshoot when needed. Taser dispo:  People who have been tased do remarkably well and complications are rare.   In a review of tasers used by law enforcement, Vilke et al. found that there was no need for routine laboratory testing or observation, as there was ‘no evidence of dangerous laboratory abnormalities, physiologic changes, or immediate or delayed cardiac ischemia or dysrhythmias after exposure to electrical discharges of up to 15 s.”  Subsequent studies with minors less than 16 years of age found similar results. Special note on the patient with agitated delirium or stimulant intoxication: treat these patients carefully, as the organic problem that got them tased in the first place still needs to be addressed, and substances such as PCP, cocaine, and methamphetamines are all cardiac irritants and may predispose them to dysrythmias. Case 4: Adolescent in full arrest after lightening strike Patients who are struck by direct current like lightening should be treated aggressively, because the reason for their cardiac arrest is often reversible if treated quickly.  Either the current sent the victim into a dysrhythmia, or it caused a temporary paralysis of the thoracic muscles, resulting in a primary respiratory arrest. For victims of a lightning strike, classically we use reverse triage – normally, those in full arrest are triaged as black, deceases.  In high-voltage and lightening injuries, we tend to those in full arrest first, because you might quickly reverse them, and can move on to the next patient triaged red, or immediate. High-voltage injuries are a multi-trauma – other sequelae include pulmonary edema, paralysis, ileus, and cataracts, in addition to the more immediate cardiac, musculoskeletal, neurologic, and renal considerations. Regardless of the exposure, obtain an ECG and look for bundle branch block, heart block, and dysrhythmias, since those will change disposition.  In those who are injured, consider a basic metabolic panel, looking for potassium, calcium, and creatinine.  A creatine phosphokinase or total CK will screen for rhabdomyolysis.  Troponin is not predictive of the extent of direct myocardial damage, but get it if you think there might be a stress-induced, or type II MI.  Radiography as needed depending on the presenting associated trauma.   Take Home Points 1. Injury from electrical burns can be subtle.   Think of patients as having occult multi-trauma.   Be thorough in history and examination.  Plan to re-examine either during observation in the ED, or in close outpatient follow-up. 2. Discharge patients with low-voltage injury, no symptoms, and a normal ECG.  Counsel outpatients and provide close follow-up as appropriate. 3. Admit patients with low-voltage injury with signs or symptoms such as loss of consciousness, ECG changes, or evidence of end-organ damage on laboratory screening.  Admit all patients with high-voltage injury, even if asymptomatic and a normal laboratory screen. 4. Transfer patients with high-voltage injury or significant burns to a regional burn center or trauma center. References Celik A, Ergün O, Ozok G. Pediatric electrical injuries: a review of 38 consecutive patients. J Pediatr Surg. 2004;39(8):1233-1237. Ericsson KA. Deliberate Practice and Acquisition of Expert Performance: A General Overview. Acad Emerg Med. 2008; 15:988-994. Fish RM. Electric injury, part I: treatment priorities, subtle diagnostic factors, and burns. J Emerg Med. 1999;17(6):977-983. doi:10.1016/S0736-4679(99)00127-4. Fish RM. Electric injury, part II: Specific injuries. J Emerg Med. 2000;18(1):27-34. doi:10.1016/S0736-4679(99)00158-4. Fish RM. Electric injury, part III: cardiac monitoring indications, the pregnant patient, and lightning. J Emerg Med. 2000;18(2):181-187. doi:10.1016/S0736-4679(99)00190-0. Horeczko T. “Electrical Injuries: Shocking or Subtle?” In Avoiding Common Errors in the Emergency Department, 2nd Edition. Mattu M, Swadron SP (eds). Lippincott, Williams & Wilkins. Phiadelphia. 2016. (In Press). Rai J, Jeschke MG, Barrow RE, Herndon DN. Electrical Injuries: A 30-Year Review. J Trauma Acute Care Surg. 1999;46(5):933-936. Vilke GM, Bozeman WP, Chan TC. Emergency department evaluation after conducted energy weapon use: review of the literature for the clinician. J Emerg Med. 2011; 40(5):598-604. This post and podcast are dedicated to Joelle Donofrio, MD, FAAP for her tireless care of children, in the ED and in the field.  A special thank you and dedication to Cliff Reid, BM, FRCP(Glasg), FRCSEd(A&E), FRCEM, FACEM, FFICM, FCCP, EDIC, DCH, DipIMC, RCSEd, DipRTM, RCSEd, CCPU, CFEU for his transformative intelligence and educational verve.

This week podcast focuses on esophageal food impaction and pearls + pitfalls in the diagnosis of peds appendicitis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_21_0_Final.m4a Download Leave a Comment Tags: Appendicitis, Food Impaction, Pediatrics Show Notes REBEL Cast: November 2015: All Vascular Access Episode Tibbling L et al. Effect of spasmolytic drugs on esophageal foreign bodies. Dysphagia 1995; 10(2): 126-7. PMID: 7600855 Samuel M. Pediatric appendicitis score. J Pediatr Surg 2002; 37(6): 877-81. PMID: 12037754 Ross MJ et al. Outcomes of children with suspected appendicitis and incompletely visualized appendix on ultrasound. Acad Emerg Med 2015; 21(5): 538-42. PMID: 24842505

This week podcast focuses on esophageal food impaction and pearls + pitfalls in the diagnosis of peds appendicitis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_21_0_Final.m4a Download Leave a Comment Tags: Appendicitis, Food Impaction, Pediatrics Show Notes REBEL Cast: November 2015: All Vascular Access Episode Tibbling L et al. Effect of spasmolytic drugs on esophageal foreign bodies. Dysphagia 1995; 10(2): 126-7. PMID: 7600855 Samuel M. Pediatric appendicitis score. J Pediatr Surg 2002; 37(6): 877-81. PMID: 12037754 Ross MJ et al. Outcomes of children with suspected appendicitis and incompletely visualized appendix on ultrasound. Acad Emerg Med 2015; 21(5): 538-42. PMID: 24842505

This week podcast focuses on esophageal food impaction and pearls + pitfalls in the diagnosis of peds appendicitis. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_21_0_Final.m4a Download Leave a Comment Tags: Appendicitis, Food Impaction, Pediatrics Show Notes REBEL Cast: November 2015: All Vascular Access Episode Tibbling L et al. Effect of spasmolytic drugs on esophageal foreign bodies. Dysphagia 1995; 10(2): 126-7. PMID: 7600855 Samuel M. Pediatric appendicitis score. J Pediatr Surg 2002; 37(6): 877-81. PMID: 12037754 Ross MJ et al. Outcomes of children with suspected appendicitis and incompletely visualized appendix on ultrasound. Acad Emerg Med 2015; 21(5): 538-42. PMID: 24842505 Parienti JJ et al.