Podcasts about pediatr emerg care

Contributor: Aaron Lessen, MD Educational Pearls: How do we take care of kids in severe pain? There are many non-pharmacologic options for pain (i.e. ice, elevation) as well as more conventional medication options (i.e. acetaminophen, NSAIDS) but in severe pain stronger medications might be indicated. These stronger medications include options such as IV morphine, a subdissociative dose of ketamine, as well as intranasal fentanyl. Intranasal fentanyl has many advantages: Studies have shown it might be more effective early on in controlling pain, as in the first 15-20 minutes after administration, and then becomes equivalent to other pain control options Total adverse effects were also lower with IN fentanyl, including low rates of nausea and vomiting To administer, use the IV formulation with an atomizer and spray into the nose; therefore, you do not need an IV line Dose is 1-2 micrograms per kilogram, can be redosed once at 10 minutes.  Don't forget about gabapentinoids for neuropathic pain, muscle relaxants for muscle spasms, and nerve blocks when appropriate. (Disclaimer: muscle relaxers have not been well studied in children) References Alsabri M, Hafez AH, Singer E, Elhady MM, Waqar M, Gill P. Efficacy and Safety of Intranasal Fentanyl in Pediatric Emergencies: A Systematic Review and Meta-analysis. Pediatr Emerg Care. 2024 Oct 1;40(10):748-752. doi: 10.1097/PEC.0000000000003187. Epub 2024 Apr 11. PMID: 38713846. Bailey B, Trottier ED. Managing Pediatric Pain in the Emergency Department. Paediatr Drugs. 2016 Aug;18(4):287-301. doi: 10.1007/s40272-016-0181-5. PMID: 27260499. Hadland SE, Agarwal R, Raman SR, Smith MJ, Bryl A, Michel J, Kelley-Quon LI, Raval MV, Renny MH, Larson-Steckler B, Wexelblatt S, Wilder RT, Flinn SK. Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline. Pediatrics. 2024 Sep 30:e2024068752. doi: 10.1542/peds.2024-068752. Epub ahead of print. PMID: 39344439. Summarized by Jeffrey Olson, MS4 | Edited by Jorge Chalit, OMS4 Donate: https://emergencymedicalminute.org/donate/

Contributor: Aaron Lessen MD Educational Pearls: What is Carbamazepine (Tegretol)? Carbamazepine is an anti-epileptic drug with mood-stabilizing properties that is used to treat bipolar disorder, epilepsy, and neuropathic pain. It functions primarily by blocking sodium channels which can prevent repetitive action potential firing. What are the symptoms of an overdose? Common initial signs include diminished conscious state, nystagmus, ataxia, hyperreflexia, CNS depression, dystonia, and tachycardia Severe toxicity can cause seizures, respiratory depression, decreased myocardial contractility, pulmonary edema, hypotension, and dysrhythmias. How is an overdose treated? An overdose is treated with large doses of activated charcoal and correction of electrolyte disturbances. Be ready to intubate given the potential for respiratory depression. Carbamazepine is moderately dialyzable and dialysis is recommended in severe overdoses. Additional educational pearl: Individuals in correctional facilities can occasionally self-administer medications which means that medication overdose should still be on the differential for any of these individuals. References Epilepsies in children, Young People and adults: NICE guideline [NG217]. National Institute for Health and Care Excellence. (2022, April 27). https://www.nice.org.uk/guidance/ng217  Ghannoum M, Yates C, Galvao TF, Sowinski KM, Vo TH, Coogan A, Gosselin S, Lavergne V, Nolin TD, Hoffman RS; EXTRIP workgroup. Extracorporeal treatment for carbamazepine poisoning: systematic review and recommendations from the EXTRIP workgroup. Clin Toxicol (Phila). 2014 Dec;52(10):993-1004. doi: 10.3109/15563650.2014.973572. Epub 2014 Oct 30. PMID: 25355482; PMCID: PMC4782683. Seymour JF. Carbamazepine overdose. Features of 33 cases. Drug Saf. 1993 Jan;8(1):81-8. doi: 10.2165/00002018-199308010-00010. PMID: 8471190. Spiller HA. Management of carbamazepine overdose. Pediatr Emerg Care. 2001 Dec;17(6):452-6. doi: 10.1097/00006565-200112000-00015. PMID: 11753195. Tran NT, Pralong D, Secrétan AD, Renaud A, Mary G, Nicholas A, Mouton E, Rubio C, Dubost C, Meach F, Bréchet-Bachmann AC, Wolff H. Access to treatment in prison: an inventory of medication preparation and distribution approaches. F1000Res. 2020 May 13;9:357. doi: 10.12688/f1000research.23640.3. PMID: 33123347; PMCID: PMC7570324. Summarized by Jeffrey Olson, MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII  

Show Notes for Episode 27 of “The 2 View” – Brain abscesses, torsion, and delirium. Brain Abscesses Accorsi EK, Hall M, Hersh AL, Shah SS, Schrag SJ, Cohen AL. Notes from the Field: Update on Pediatric Intracranial Infections - 19 States and the District of Columbia, January 2016-March 2023. MMWR Morb Mortal Wkly Rep. CDC, Centers for Disease Control and Prevention. https://www.cdc.gov/mmwr/volumes/72/wr/mm7222a5.htm Brook I. Clinical Case. Brain Abscess Clinical Presentation. Medscape.com. https://reference.medscape.com/article/212946-clinical Goodman B. Doctors watching for more cases after mysterious cluster of brain infections strikes kids in southern Nevada. CNN. CNN Health. https://www.cnn.com/2023/04/28/health/brain-abscess-cluster-nevada/index.html The Center for Medical Education. 23 - Dear Doctor, Skin Closures, and Wound Management. 2 View: Emergency Medicine PAs & NPs. https://2view.fireside.fm/23 What's “ordinary negligence”? //Missed brain abscess//Special offer. Mad Mimi. Medical Malpractice Insights: Learning from Lawsuits. https://madmimi.com/s/3fc5711 Testicular Torsion Lukosiute-Urboniene A, Nekrosius D, Dekeryte I, Kilda A, Malcius D. Clinical risk factors for testicular torsion and a warning against falsely reassuring ultrasound scans: a 10-year single-centre experience. Emerg Med J. BMJ Journals. https://emj.bmj.com/content/40/2/134.info Mellick LB, Watters BC. The Torsed Testicle Traction Technique and 2 Case Reports. Pediatr Emerg Care. https://journals.lww.com/pec-online/Citation/2023/05000/TheTorsedTesticleTractionTechniqueand2_Case.14.aspx Sessions AE, Rabinowitz R, Hulbert WC, Goldstein MM, Mevorach RA. Testicular torsion: direction, degree, duration and disinformation. J Urol. PubMed. NIH: National Library of Medicine. National Center for Biotechnology Information. https://pubmed.ncbi.nlm.nih.gov/12544339/ Ovarian Torsion Long B, Koyfman A, Gottlieb M. Dispelling 5 Ovarian Torsion Myths. ACEP Now. https://www.acepnow.com/article/dispelling-5-ovarian-torsion-myths/ Ovarian Torsion. Acep.org. ACEP Emergency Ultrasound Section. https://www.acep.org/emultrasound/newsroom/sept2020/ovarian-torsion Spinelli C, Piscioneri J, Strambi S. Adnexal Torsion in Adolescents: Update and review of the literature. https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/08/adnexal-torsion-in-adolescents Swenson DW, Lourenco AP, Beaudoin FL, Grand DJ, Killelea AG, McGregor AJ. Ovarian torsion: Case-control study comparing the sensitivity and specificity of ultrasonography and computed tomography for diagnosis in the emergency department. European Journal of Radiology. ScienceDirect. https://edus.ucsf.edu/sites/edus.ucsf.edu/files/wysiwyg/1-s2.0-S0720048X14000023-main.pdf Delirium ACEP's Position on Hyperactive Delirium. American College of Emergency Physicians. https://www.acep.org/news/acep-newsroom-articles/aceps-position-on-hyperactive-delirium Hatten BW, Bonney C, Dunne RB, et al. ACEP Task Force Report on Hyperactive Delirium with Severe Agitation in Emergency Settings, Approved by the ACEP Board of Directors, June 23, 202. American College of Emergency Physicians. https://www.acep.org/siteassets/new-pdfs/education/acep-task-force-report-on-hyperactive-delirium-final.pdf Hayes BD, O'Brien M. Should Diphenhydramine be included in an Acute Agitation Regimen? AliEM: Academic Life in Emergency Meedicine. https://www.aliem.com/diphenhydramine-acute-agitation-regimen/ Psychiatric Patient. American College of Emergency Physicians. https://www.acep.org/patient-care/clinical-policies/Psychiatric-Patient Reuben. Emergency Department Agitated Patient Treatment Map. Emergency Medicine Updates. https://emupdates.com/danger/ Veraart JKE, Smith-Apeldoorn SY, Bakker IM, et al. Pharmacodynamic Interactions Between Ketamine and Psychiatric Medications Used in the Treatment of Depression: A Systematic Review. Int J Neuropsychopharmacol. Oxford Academic. https://academic.oup.com/ijnp/article/24/10/808/6309481?login=false Prescription Drug Monitoring Programs D'Souza RS, Lang M, Eldrige JS. Prescription Drug Monitoring Program. StatPearls Publishing. NIH: National Library of Medicine. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK532299/ Something Sweet Brito C. Bobi, the world's oldest dog, turns 31 years old. CBS News. https://www.cbsnews.com/news/bobi-the-worlds-oldest-dog-turns-31-years-old/ Recurring Sources Center for Medical Education. http://ccme.org The Proceduralist. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com

In our last episode, we spoke with negotiations expert and founder of the Center for Leadership, Dr. Cheri Hobgood, about the art of a good negotiation. This week, we've partnered with Women in PEM again to explore how negotiations can play out in the real world of emergency medicine. Dr. Selena Hariharan returns to share her personal experience and Dr. Elizabeth Alpern offers some concrete advice on how to prepare for an interview, read a contract, and make the outcome of the negotiation beneficial to all parties. It's all about time, money, and power! Was this series helpful to you? Have you been able to put some of these strategies into practice? We'd love to know! Tag us on social media, @empulsepodcast, or reach out via email empulsepodcast@gmail.com, or through our website, ucdavisem.com. Please encourage your friends and colleagues to listen and share their stories, too! ***Please rate us and leave us a review on iTunes! It helps us reach more people.*** Hosts: Dr. Julia Magaña, Associate Professor of Pediatric Emergency Medicine at UC Davis Dr. Sarah Medeiros, Associate Professor of Emergency Medicine at UC Davis Guests: Dr. Elizabeth Alpern, Professor of Pediatrics, Division Head of Emergency Medicine, and Associate Chair for Faculty Development Dr. Selena Hariharan, Women in PEM Co-Chair and Professor of Pediatrics Division of Pediatric Emergency Medicine at Cincinnati Children's Hospital Resources: Women in PEM SoMe: @womeninpem Email: womeninpem@gmail.com Center for Leadership Life Barrick L, Bechtel K, Cooper G, Hall JE, Levine DA, Reichard KG, Reed J, White ML, Langhan ML. Building the Foundation: A Call to Action for Baseline Data. Pediatr Emerg Care. 2023 Apr 1;39(4):294-295. doi: 10.1097/PEC.0000000000002902. Epub 2023 Jan 8. PMID: 36625447. Chumpitazi CE, Allister L, Cho C, Hoffmann JA, Hsu D, Iyer M, Mangold K, Marino M, Randell KA, Ponce H, Hariharan S. Career Development in Pediatric Emergency Medicine: What Do We Need? Pediatr Emerg Care. 2022 Sep 1;38(9):e1552-e1556. doi: 10.1097/PEC.0000000000002720. Epub 2022 Apr 28. PMID: 35470318; PMCID: PMC9912171.  *** Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.

Negotiating what you need and want in your career is an essential skill, for any emergency medicine physician - well, for anyone, really! So, whether you are in academic or community practice, or something completely unrelated, this episode is for you. We've teamed up with Women in PEM to bring you this illuminating interview with Dr. Cherri Hobgood, an emergency physician, expert in negotiations, and founder of the Center for Leadership Life. She takes us through the ins and outs of negotiating, including preparation, tactics, and even reading body language, to help us learn the art of a successful negotiation.  Do you find negotiations challenging? What strategies have been most successful for you? Tag us on social media, @empulsepodcast, or reach out via email empulsepodcast@gmail.com, or through our website, ucdavisem.com. Please encourage your friends and colleagues to listen and share their stories, too! ***Please rate us and leave us a review on iTunes! It helps us reach more people.*** Hosts: Dr. Julia Magaña, Associate Professor of Pediatric Emergency Medicine at UC Davis Dr. Sarah Medeiros, Associate Professor of Emergency Medicine at UC Davis Guests: Dr. Cherri Hobgood, Founder of the Center for Leadership Life, Certified Executive Coach, and Professor of Emergency Medicine at Penn State Health Dr. Selena Hariharan, Women in PEM Co-Chair and Professor of Pediatrics Division of Pediatric Emergency Medicine at Cincinnati Children's Hospital Resources: Women in PEM SoMe: @womeninpem Email: womeninpem@gmail.com Center for Leadership Life Barrick L, Bechtel K, Cooper G, Hall JE, Levine DA, Reichard KG, Reed J, White ML, Langhan ML. Building the Foundation: A Call to Action for Baseline Data. Pediatr Emerg Care. 2023 Apr 1;39(4):294-295. doi: 10.1097/PEC.0000000000002902. Epub 2023 Jan 8. PMID: 36625447. Chumpitazi CE, Allister L, Cho C, Hoffmann JA, Hsu D, Iyer M, Mangold K, Marino M, Randell KA, Ponce H, Hariharan S. Career Development in Pediatric Emergency Medicine: What Do We Need? Pediatr Emerg Care. 2022 Sep 1;38(9):e1552-e1556. doi: 10.1097/PEC.0000000000002720. Epub 2022 Apr 28. PMID: 35470318; PMCID: PMC9912171.  *** Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.

What are the red flags when we see a patient with torticollis?   Check out the paper mentioned. Starc M, Norbedo S, Tubaro M, Ronfani L, Bassanese G, Barbi E. Red Flags in Torticollis: A Historical Cohort Study. Pediatr Emerg Care. 2018 Jul;34(7):463-466.  https://pubmed.ncbi.nlm.nih.gov/29298248/    Check out the RCH Melbourne pages on Acquired and Congenital Torticollis https://www.rch.org.au/clinicalguide/guideline_index/Acquired_Torticollis/ https://www.rch.org.au/clinicalguide/guideline_index/Congenital_Torticollis/    And don't forget to check out the Wolfgang - https://www.instagram.com/wolfgang2242/?hl=en    www.rnzcuc.org.nz podcast@rnzcuc.org.nz https://www.facebook.com/rnzcuc https://twitter.com/rnzcuc   Music licensed from www.premiumbeat.com Full Grip by Score Squad   This podcast is intended to assist in ongoing medical education and peer discussion for qualified health professionals.  Please ensure you work within your scope of practice at all times.  For personal medical advice always consult your usual doctor

Date: August 25th, 2022 Reference: Martin et al. Single-dose dexamethasone is not inferior to 2 doses in mild to moderate pediatric asthma exacerbations in the emergency department. Pediatr Emerg Care. 2022 Guest Skeptic: Dr. Harrison Hayward is a Pediatric Emergency Medicine fellow at Children's National Hospital. He finished his General Pediatrics residency at Yale-New Haven Hospital. As […]

Contributor: Aaron Lessen, MD Educational Pearls: Intranasal medication administration is a convenient, quick, and relatively painless option for pediatric patients Often used as an initial medication to help control pain in children prior to establishing an IV Using an atomizer is preferred when administering intranasal medications The syringe should be angled towards the ipsilateral eye or occiput rather than straight upwards Do not administer more than 1 mL of fluid per nostril as volumes greater than 1 mL are not sufficiently absorbed Intranasal medication doses differ from the traditional IV dosages and have a slower onset of action References Del Pizzo J, Callahan JM. Intranasal medications in pediatric emergency medicine. Pediatr Emerg Care. 2014;30(7):496-501; quiz 502-494. Fantacci C, Fabrizio GC, Ferrara P, Franceschi F, Chiaretti A. Intranasal drug administration for procedural sedation in children admitted to pediatric Emergency Room. Eur Rev Med Pharmacol Sci. 2018;22(1):217-222. Rech MA, Barbas B, Chaney W, Greenhalgh E, Turck C. When to Pick the Nose: Out-of-Hospital and Emergency Department Intranasal Administration of Medications. Ann Emerg Med. 2017;70(2):203-211. Schoolman-Anderson K, Lane RD, Schunk JE, Mecham N, Thomas R, Adelgais K. Pediatric emergency department triage-based pain guideline utilizing intranasal fentanyl: Effect of implementation. Am J Emerg Med. 2018;36(9):1603-1607.   Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD & Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today!

Contributor: Aaron Lessen, MD Educational Pearls: Recent study looking at a pediatric emergency department to determine what percentage of patients after intubation received sedation within 10 minutes after intubation About 25% of the patients in the study received sedation within 10 minutes after intubation Only 75% of the patients in the study received sedation in the ED at some point after intubation Those who received rocuronium were less likely to received sedation post-intubation References Berg K, Gregg V, Cosgrove P, Wilkinson M. The Administration of Postintubation Sedation in the Pediatric Emergency Department. Pediatr Emerg Care. 2021;37(11):e732-e735. doi:10.1097/PEC.0000000000001744 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD   The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account.  Donate to EMM today!

On this episode, we're lucky have a special guest from Texas Children's Hospital, pediatric sedation and pain management expert, Dr. Corrie Chumpitazi. Nitrous oxide has been in our protocols here at MCHD for some time, but probably doesn't get the recognition and appreciation that it deserves. We'll discuss NO history, dosing, indications, contraindications, and side-effects. Listen to learn why we all should be incorporating more Nitrous Oxide into our daily EMS practice. https://www.acep.org/patient-care/map/map-nitrous-oxide-tool/ REFERENCES 1. Ducassé JL et al (2013). Nitrous oxide for early analgesia in the emergency setting: a randomized, double-blind multicenter prehospital trial. Acad Emerg Med. 2013 Feb;20(2):178-84. 2. Annequin D and Carbajal R, et al; Fixed 50% Nitrous Oxide Oxygen Mixture for Painful Procedures: A French Survey. Pediatrics. 2000; 105; e47. 3. Collado V, Emmanuel N, et al; Expert Opinion: a Review of the Safety of 50% Nitrous Oxide/Oxygen in Conscious Sedation. Drug Safety. 2007, 6(5): 559-571. 4. Sanders R, Weimann J, Maze M; Biologic Effects of Nitrous Oxide. Anesthesiology. 2008, 109: 707-722 5. Gall O, Annequin D, et al; Adverse Events of Premixed Nitrous Oxide and Oxygen for Procedural Sedation in Children. Lancet. 2001; 358: 1514-15. 6. Tobias, JD, Review Article: Applications of Nitrous Oxide for Procedural Sedation in the Pediatric Population. Pediatric Emergency Care. 2013; 29: 245-265. 7. Onody P, Gil P, Hennequin M. Safety of Inhalation of a 50% Nitrous Oxide/Oxygen Premix: A Prospective Study of 35,828 Administrations. Drug Safety. 2006; 29(7):633-640. 8. American Academy of Pediatric Dentistry. (2013). Guideline on use of nitrous oxide for pediatric dental patients. Retrieved September 3, 2013, from www.aapd.org: http://www.aapd.org/media/Policies_Guidelines/G_Nitrous.pdf 9. Heinrich M, Menzel C, Hoffmann F, et al. Self-administered procedural analgesia using nitrous oxide/oxygen (50:50) in the pediatric surgery emergency room: effectiveness and limitations. Eur J Pediatr Surg. 2015;25(3):250-6. 10. 28. Pasaron R, Burnweit C, Zerpa J, et al. Nitrous oxide procedural sedation in non-fasting pediatric patients undergoing minor surgery: a 12-year experience with 1,058 patients. Pediatr Surg Int. 2015;31(2):173-80. 11. 29. Zier JL, Liu M. Safety of high-concentration nitrous oxide by nasal mask for pediatric procedural sedation: experience with 7802 cases. Pediatr Emerg Care. 2011;27(12):1107-12. 12. 30. Gamis AS, Knapp JF, Glenski JA. Nitrous oxide analgesia in a pediatric emergency department. Ann Emerg Med. 1989;18(2):177-81. 13. 31. Martin HA, Noble M, Wodo N. The Benefits of Introducing the Use of Nitrous Oxide in the Pediatric Emergency Department for Painful Procedures. J Emerg Nurs. 2018;44(4):331-5.

In this three-part series with discuss the essentials of natural airway sedation for pediatric intensivists. During our conversation we discuss:1.  Why this topic is so important for PICU physicians2.  Procedural sedation vs. general anesthesia3.  Conscious sedation???4.  Safety considerations, risk factors and adverse events5.  Patient selection6.  Drug selection7.  Appropriate monitoring8.  Rescue medications. We finish with a discussion of common clinical scenarios. About our guest:Dr. Pradip Kamat is an Associate Professor of Pediatrics at Emory School of Medicine and practicing pediatric intensivist at Children's Healthcare of Atlanta. His clinical and research interests are in procedural sedation and education. We are very excited to have him on our podcast.Dr. Kamat is also active in PICU open access education. Please check out the PICU Doc On Call podcast co-hosted by Rahul Damania and him at https://picudoconcall.org How to support PedsCrit?Please share, like, rate and review on Apple Podcasts or Spotify!Donations appreciated @PedsCrit on Venmo --100% of all funds will go to supporting the show to keep this project going.Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.com for detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updatesThanks again for listening!  References and further reading:Coté CJ, Wilson S; AMERICAN ACADEMY OF PEDIATRICS; AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics. 2016 Jul;138(1):e20161212. doi: 10.1542/peds.2016-1212. PMID: 27354454.Emrath ET, Stockwell JA, McCracken CE, Simon HK, Kamat PP. Provision of deep procedural sedation by a pediatric sedation team at a freestanding imaging center. Pediatr Radiol. 2014 Aug;44(8):1020-5. doi: 10.1007/s00247-014-2942-z. Epub 2014 May 24. PMID: 24859263.Grunwell JR, McCracken C, Fortenberry J, Stockwell J, Kamat P. Risk factors leading to failed procedural sedation in children outside the operating room. Pediatr Emerg Care. 2014 Jun;30(6):381-7. doi: 10.1097/PEC.0000000000000143. PMID: 24849275.Hooper MC, Kamat PP, Couloures KG. Evaluating the Need for Pediatric Procedural Sedation Training in Pediatric Critical Care Medicine Fellowship. Pediatr Crit Care Med. 2019 Mar;20(3):259-261. doi: 10.1097/PCC.0000000000001809. PMID: 30431555.Kamat PP, McCracken CE, Simon HK, Stormorken A, Mallory M, Chumpitazi CE, Cravero JP. Trends in Outpatient Procedural Sedation: 2007-2018. Pediatrics. 2020 May;145(5):e20193559. doi: 10.1542/peds.2019-3559. PMID: 32332053. 

In this three-part series with discuss the essentials of natural airway sedation for pediatric intensivists. During our conversation we discuss:1.  Why this topic is so important for PICU physicians2.  Procedural sedation vs. general anesthesia3.  Conscious sedation???4.  Safety considerations, risk factors and adverse events5.  Patient selection6.  Drug selection7.  Appropriate monitoring8.  Rescue medications. We finish with a discussion of common clinical scenarios. About our guest:Dr. Pradip Kamat is an Associate Professor of Pediatrics at Emory School of Medicine and practicing pediatric intensivist at Children's Healthcare of Atlanta. His clinical and research interests are in procedural sedation and education. We are very excited to have him on our podcast.Dr. Kamat is also active in PICU open access education. Please check out the PICU Doc On Call podcast co-hosted by Rahul Damania and him at https://picudoconcall.org How to support PedsCrit?Please share, like, rate and review on Apple Podcasts or Spotify!Donations appreciated @PedsCrit on Venmo --100% of all funds will go to supporting the show to keep this project going.Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.com for detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updatesThanks again for listening!  References and further reading:Coté CJ, Wilson S; AMERICAN ACADEMY OF PEDIATRICS; AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics. 2016 Jul;138(1):e20161212. doi: 10.1542/peds.2016-1212. PMID: 27354454.Emrath ET, Stockwell JA, McCracken CE, Simon HK, Kamat PP. Provision of deep procedural sedation by a pediatric sedation team at a freestanding imaging center. Pediatr Radiol. 2014 Aug;44(8):1020-5. doi: 10.1007/s00247-014-2942-z. Epub 2014 May 24. PMID: 24859263.Grunwell JR, McCracken C, Fortenberry J, Stockwell J, Kamat P. Risk factors leading to failed procedural sedation in children outside the operating room. Pediatr Emerg Care. 2014 Jun;30(6):381-7. doi: 10.1097/PEC.0000000000000143. PMID: 24849275.Hooper MC, Kamat PP, Couloures KG. Evaluating the Need for Pediatric Procedural Sedation Training in Pediatric Critical Care Medicine Fellowship. Pediatr Crit Care Med. 2019 Mar;20(3):259-261. doi: 10.1097/PCC.0000000000001809. PMID: 30431555.Kamat PP, McCracken CE, Simon HK, Stormorken A, Mallory M, Chumpitazi CE, Cravero JP. Trends in Outpatient Procedural Sedation: 2007-2018. Pediatrics. 2020 May;145(5):e20193559. doi: 10.1542/peds.2019-3559. PMID: 32332053. 

In this three part series with discuss the essentials of natural airway sedation for pediatric intensivists. During our conversation we discuss:1.  Why this topic is so important for PICU physicians2.  Procedural sedation vs. general anesthesia3.  Conscious sedation???4.  Safety considerations, risk factors and adverse events5.  Patient selection6.  Drug selection7.  Appropriate monitoring8.  Rescue medications. We finish with a discussion of common clinical scenarios. About our guest:Dr. Pradip Kamat is an Associate Professor of Pediatrics at Emory School of Medicine and practicing pediatric intensivist at Children's Healthcare of Atlanta. His clinical and research interests are in procedural sedation and education. We are very excited to have him on our podcast.Dr. Kamat is also active in PICU open access education. Please check out the PICU Doc On Call podcast co-hosted by Rahul Damania and him at https://picudoconcall.org How to support PedsCrit?Please share, like, rate and review on Apple Podcasts or Spotify!Donations appreciated @PedsCrit on Venmo --100% of all funds will go to supporting the show to keep this project going.Thank you for listening to this episode of PedsCrit. Please remember that all content during this episode is intended for educational and entertainment purposes only. It should not be used as medical advice. The views expressed during this episode by hosts and our guests are their own and do not reflect the official position of their institutions. If you have any comments, suggestions, or feedback-you can email us at pedscritpodcast@gmail.com. Check out http://www.pedscrit.com for detailed show notes. And visit @critpeds on twitter and @pedscrit on instagram for real time show updatesThanks again for listening!  References and further reading:Coté CJ, Wilson S; AMERICAN ACADEMY OF PEDIATRICS; AMERICAN ACADEMY OF PEDIATRIC DENTISTRY. Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016. Pediatrics. 2016 Jul;138(1):e20161212. doi: 10.1542/peds.2016-1212. PMID: 27354454.Emrath ET, Stockwell JA, McCracken CE, Simon HK, Kamat PP. Provision of deep procedural sedation by a pediatric sedation team at a freestanding imaging center. Pediatr Radiol. 2014 Aug;44(8):1020-5. doi: 10.1007/s00247-014-2942-z. Epub 2014 May 24. PMID: 24859263.Grunwell JR, McCracken C, Fortenberry J, Stockwell J, Kamat P. Risk factors leading to failed procedural sedation in children outside the operating room. Pediatr Emerg Care. 2014 Jun;30(6):381-7. doi: 10.1097/PEC.0000000000000143. PMID: 24849275.Hooper MC, Kamat PP, Couloures KG. Evaluating the Need for Pediatric Procedural Sedation Training in Pediatric Critical Care Medicine Fellowship. Pediatr Crit Care Med. 2019 Mar;20(3):259-261. doi: 10.1097/PCC.0000000000001809. PMID: 30431555.Kamat PP, McCracken CE, Simon HK, Stormorken A, Mallory M, Chumpitazi CE, Cravero JP. Trends in Outpatient Procedural Sedation: 2007-2018. Pediatrics. 2020 May;145(5):e20193559. doi: 10.1542/peds.2019-3559. PMID: 32332053.

Contributor:  Peter Bakes, MD Educational Pearls: Lyme disease gives a single expanding target lesion with central clearing called erythema chronicum migrans Erythema multiforme is another targetoid rash that presents with multiple target lesions Characterized into erythema minor and major based on severity but typically resolves More severe hypersensitivity reactions include Stevens-Johnson Syndrome (30% skin involvement) SJS and TEN is associated with NSAIDS including aspirin, antiemetics like phenergan, anticonvulsants like dilantin or phenobarbital, and antibiotics like penicillin or sulfa drugs Other causes include viral illnesses like Herpes simplex virus or mycoplasma pneumoniae  Treat by removing offending agent and treat supportively with monitoring for rash progression to SJS or TEN References Trayes KP, Love G, Studdiford JS. Erythema Multiforme: Recognition and Management. Am Fam Physician. 2019 Jul 15;100(2):82-88. PMID: 31305041. Read J, Keijzers GB. Pediatric Erythema Multiforme in the Emergency Department: More Than "Just a Rash". Pediatr Emerg Care. 2017 May;33(5):320-324. doi: 10.1097/PEC.0000000000000618. PMID: 26555305. Summarized by John Spartz, MS3 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.  Donate to EMM today!

“Hot” Off the Press: Infant Fever Rule - Episode 15 Talking about neonatal fever makes most people hot under the collar! Fortunately, PECARN is on the case. Their latest paper was just published TODAY in JAMA Peds: A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. In this month’s episode, we learn about some the challenges of having a febrile infant - from a mom’s perspective. Then we discuss when, why, and how to apply the latest PECARN rule with the notorious DNK, also known as Dr. Nate Kuppermann!  What is your approach to the febrile infant? What are some of the hardest parts about providing care to our hot little ones? We want to know! Share your thoughts on social media, @empulsepodcast, or on our website, ucdavisem.com.  Hosts: Dr. Julia Magaña, Assistant Professor of Pediatric Emergency Medicine at UC Davis Dr. Sarah Medeiros, Assistant Professor of Emergency Medicine at UC Davis Guest: Dr. Nate Kuppermann, Pediatric Emergency Physician, Professor and Chair of the UC Davis Department of Emergency Medicine, Founding Chair of the PECARN Steering Committee Resources: A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections.  Nathan Kuppermann, MD, MPH1; Peter S. Dayan, MD, MSc2; Deborah A. Levine, MD3; et al. JAMA Pediatr. Published online February 18, 2019. doi:10.1001/jamapediatrics.2018.5501 Validation of the “Step-by-Step” Approach in the Management of Young Febrile Infants. Gomez B, Mintegi S, Bressan S, Da Dalt L, et. al. Pediatrics. 2016 Aug;138(2). pii: e20154381. doi: 10.1542/peds.2015-4381. Epub 2016 Jul 5. Management of the Febrile Young Infant: Update for the 21st Century.  Woll C, Neuman MI, Aronson PL. Pediatr Emerg Care. 2017 Nov;33(11):748-753. doi: 10.1097/PEC.0000000000001303. Accuracy of Complete Blood Cell Counts to Identify Febrile Infants 60 Days or Younger with Invasive Bacterial Infections.  Cruz AT, Mahajan P, Bonsu BK, Bennett JE et. al. JAMA Pediatr. 2017 Nov 6;171(11):e172927. doi: 10.1001/jamapediatrics.2017.2927. Epub 2017 Nov 6. *************************************** Ski and CME! Join us for the,UC Davis Emergency Medicine Winter Conference, March 4th-8th at the Ritz Carlton in Lake Tahoe, CA. Come play and learn with us at the Western Regional SAEM Annual Meeting, March 21-22 in beautiful Napa, CA! #WRSAEM19  Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Audio Productions for audio production services. Dr. Nathan KuppermannSarah and Julia

Today, I talk to Jonathan Singer, host of The Social Work Podcast as well as associate professor at Loyola University Chicago School of Social Work. I asked Jonathan to come on the podcast today because I’ve had this growing sense of disconnect between all the talk about social determinants of health, all the talk about how clinical care has a relatively small impact on patient outcomes compared to environmental factors, how the most important number in health care is someone’s zip code. All this talk swirling around, and rarely do social workers come up in the conversation—at least at the level that you’d think they would, given the number of years of education they have in addressing the environmental factors in question. You can learn more at socialworkpodcast.com. Jonathan B. Singer, PhD, LCSW, is associate professor of social work at Loyola University Chicago, secretary of the American Association of Suicidology, and an award-winning author and podcaster. His research on youth suicide and cyberbullying has been featured on NPR and Fox, and in Time magazine and The Guardian. He is the founder and host of the award-winning Social Work Podcast, with over 5 million episode downloads and 30,000 followers on social media. He lives in Evanston, Illinois, with his wife and 3 children and can be found on Twitter as @socworkpodcast and Facebook at facebook.com/swpodcast. Studies: Moniz C. Social work and the social determinants of health perspective: a good fit. Health Soc Work. 2010;35(4):310-313. Beth Wharff and her social work colleagues at Boston Children’s Hospital wrote about the success of their interventions with suicidal youth who presented at the emergency department: Wharff EA, Ginnis KB, Ross AM, White EM, White MT, Forbes PW. Family‑based crisis intervention with suicidal adolescents: a randomized clinical trial [published online ahead of print February 2017]. Pediatr Emerg Care. doi:10.1097/PEC.0000000000001076. 01:56 What #socialworkers do and think about things. 03:34 Getting caught up on terms like “#socialdeterminants.” 04:10 #Healthcare vs #socialcare. 04:23 “Health care is part of social care, rather than social care being part of health care.” 05:25 “You can’t be effective in people’s lives without being #interdisciplinary.” 07:16 Understanding “legitimate” #dischargeplanning. 08:50 Social workers vs nurses. 09:04 “#Nursing is essential.” 09:32 “[Social workers] have the personal connection to make sure this is happening.” 09:57 “#Nurses are trained not to override the #doctor.” 10:18 “That sort of level of mutual respect is essential.” 10:51 The lack of appreciation for the skills that a #socialworker has. 12:58 “As with anything, there’s a range.” 14:31 The myth of the social worker. 15:00 “Let’s bring in #socialwork when we don’t know what else to do.”—#Hospitals 17:36 Primary care provider (#PCP) as the “quarterback of care.” 18:55 “It’s a problem in perception.” 19:30 Social workers and #efficiency in #medicine. 20:11 Jonathan’s advice to #payer and #healthsystem executives. 20:23 “Stop thinking of social workers as discharge planners.” 21:41 “Have social workers do social care.” 21:49 “Have social workers in … authority-making positions. 23:45 “My expertise matters.” 25:03 The need for interdisciplinary teams. 26:21 Finding a middle ground for patients who want to leave their hospital care but aren’t medically ready to go home. 29:09 “What’s the role of the social worker?” 

Caring for kids in the ED can be challenging - they often can’t (or won’t) tell you what’s wrong or where it hurts; they may have trouble sitting still during an exam or procedure; and their screams put everyone on edge. But let’s think about it from their perspective. It must be pretty confusing and frightening at times. Did you ever have to go to the ED as a kid? Do you remember what it was like? We ask some kids to share their thoughts and experiences. Then we get some valuable tips from the experts - Child Life Specialists, Pediatric ED Nurses, and Pediatric Emergency Medicine Physicians, including our own Dr. Julia Magaña. Learn what you can do to improve the ED experience for both you and your young patients. What tips do you have for taking care of kids in the ED? Did you try any of the things we mentioned in this episode? If so, did they work for you? We want to know! Share your thoughts on social media, @empulsepodcast, or on our website, ucdavisem.com.  Hosts: Dr. Julia Magaña, Assistant Professor of Pediatric Emergency Medicine at UC Davis Dr. Sarah Medeiros, Assistant Professor of Emergency Medicine at UC Davis Guests: The kids: Isa, Jordan, Benny, Katelyn, Wesley and Elia UC Davis Department of Emergency Medicine Child Life Specialists, Nurses and Pediatric Emergency Medicine Physicians. Resources: DistrACTION Cards that Julia mentioned Information and protocols for using intranasal medications at www.intranasal.net Wong-Baker FACES pain scale FLACC Score for pain in infants ACEP Guidelines for Procedural Sedation and Analgesia in the Emergency Department (2013) An Evidence-Based Approach to Minimizing Acute Procedural Pain in the Emergency Department and Beyond. Ali S, McGrath T, Drendel AL. Pediatr Emerg Care. 2016 Jan;32(1):36-42; quiz 43-4. doi: 10.1097/PEC.0000000000000669. Review. Patient- and family-centered care of children in the emergency department. Dudley N, Ackerman A, Brown KM, Snow SK; American Academy of Pediatrics Committee on Pediatric Emergency Medicine; American College of Emergency Physicians Pediatric Emergency Medicine Committee; Emergency Nurses Association Pediatric Committee. Pediatrics. 2015 Jan;135(1):e255-72. doi: 10.1542/peds.2014-3424. Ten Practical Ways to Make Your ED Practice Less Painful and More Child-Friendly Amy L.DrendelDO, MS*SaminaAliMDCM, Clinical Pediatric Emergency Medicine Volume 18, Issue 4, December 2017, Pages 242-255 ********************************************************* Ski and CME! Join us for the UC Davis Emergency Medicine Winter Conference, March 4th-8th at the Ritz Carlton in Lake Tahoe. Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Audio Productions for audio production services.

Author: Aaron Lessen, MD Educational Pearls:   Injuries from penetrating pharyngeal trauma  are often subtle on examination in children Potentially serious complications including carotid artery injury, mediastinitis from spreading infection, or airway compromise from hematoma formation Imaging choice is typically CTA to assess for vascular injuries These injuries may require antibiotics   References:   Zonfrillo MR, Roy AD, Walsh SA. Management of pediatric penetrating oropharyngeal trauma. Pediatr Emerg Care. 2008 Mar;24(3):172-5. doi: 10.1097/PEC.0b013e3181669072. PubMed PMID: 18347498. Sasaki T, Toriumi S, Asakage T, Kaga K, Yamaguchi D, Yahagi N. The toothbrush: a rare but potentially life-threatening cause of penetrating oropharyngeal trauma in children. Pediatrics. 2006 Oct;118(4):e1284-6. PubMed PMID: 17015515. Summary by Travis Barlock, MS4  | Edited by Erik Verzemnieks, MD

Ovarian torsion is like the MI of the pelvis.  Sometimes all it takes is a good story to investigate. When to worry, when to walk it off, and when to work it up:     What is the typical presentation of ovarian torsion? There is none.  The presentation varies so much, we need a rule to live by: Unilateral pelvic pain in a girl is ovarian torsion until proven otherwise.  This includes the cases in which you are concerned about appendicitis.  They both can be fake-outs. Often the pain is severe and abrupt, but trying to tease this out is often not fruitful. Here are the often-reported signs and symptoms associated with ovarian torsion: Stabbing pain, 70% Nausea and vomiting, 70% Sudden, sharp pain in the lower abdomen, 59% Pain radiating to the back, flank, or groin, 51% Peritoneal signs, 3% Fever, less than 2% And of course…no pain on presentation…30%...intermittent torsion. What is the mechanism of ovarian torsion? Structurally abnormal ovary (including cysts) that causes the ovary to flop over and twist on its vascular axis Hypermobile ovary with vigorous movement twists on its vascular pedicle and cuts off blood supply The Dual Blood Supply to the Ovaries: Why Doppler Flow can Fool You What ultrasound findings suggest ovarian torsion? The enlarged hyper or hypoechoic ovary from generalized edema Peripherally displaced follicles with hyperechoic central stroma – this is called the string of pearls sign, because the stroma is edematous, leaving the follicles to stand out A midline ovary – if the ovary magically makes it to midline, something is up Free fluid in the pelvis – this is seen in the vast majority of cases As far as Doppler flow goes, you may see one of several scenarios: Little or no venous flow – this is very common, as we talked about, because the low pressure venous system is the first to take a hit in torsion Totally absent arterial flow – this is not as common, but totally diagnostic There may be no flow in diastole, or the flow may even be reversed. Rememver the red and blue of dopple does not correspond to arterial and venous.  Doppler is a vector.  Red is fluid coming towards the probe, blue is programmed to present flow away from the probe.  If you have just one or the other, then by definition there is a problem with the vascular circuit. Other things you may see on ultrasound include focal tenderness with the probe, or the whirlpool sign – this is a twisted vascular pedicle.   In children, is there an ovarian size (volume) that rules out torsion?” In the Journal of Pediatric Radiology, Servaes et al catalogued the ultrasound findings in children with surgically confirmed torsion over a 12 year period.  In this case series of 41 patients, the median age was 11.  The age range was one month old to 21 years of age.  They found that in torsed ovaries, the ovarian volume was 12 x that compared to the normal, non-torsed contralateral ovary. That is to say, in this case series all torsed ovaries were larger than the normal contralateral ovary.   Summary Sudden unilateral lower abdominal or pelvic pain in a female? Think torsion. Have a low threshold for investigation. Know the performance characteristics of ultrasound findings and involve a gynecologist early.   This post and podcast are dedicated to Stephanie Doniger, MD for her enthusiasm, spirit, and expertise in #MedEd #FOAMed #FOAMped #POCUS    References Abe M, Sarihan H. Oophoropexy in children with ovarian torsion. Eur. J. Pediatr. Surg. 2004;14:168. Aziz D, Davis V, Allen L, Langer J. Ovarian torsion in children: Is oophorectomy necessary? J. Pediatr. Surg. 2004;39:750-3. Bristow RE, Nugent AC, Zahurak ML, et al. Impact of surgeon specialty on ovarian-conserving surgery in young females with an adnexal mass. J. Adolesc. Health 2006;39:411. Chang YJ, Yan DC, Kong MS, et al. Adnexal torsion in children. Pediatr. Emerg. Care. 2008;24:534-7. Conforti A, Giorlandino C, Bagolan P. Fetal ovarian cysts management and ovarian prognosis: a report of 82 cases. J. Pediatr. Surg. 2009;44:868; author reply 868-9. Guthrie BD, Adler MD, Powell EC. Incidence and trends of pediatric ovarian torsion hospitalizations in the United States, 2000-2006. Pediatrics 2010;125:532-8. Epub 2010 Feb 1. Houry D, Abbott JT. Ovarian torsion: a fifteen-year review. Ann. Emerg. Med. 2001;38:156-9. Huang TY, Lau BH, Lin LW, Wang TL, Chong CF, Chen CC. Ovarian cyst torsion in a toddler. Am. J. Emerg. Med. 2009;27:632, e1-3. Hurh PJ, Meyer JS, Shaaban A. Ultrasound of a torsed ovary: characteristic gray-scale appearance despite normal arterial and venous flow on Doppler. Pediatr. Radiol. 2002;32:586-8. Epub 2002 May 25. Kokoska E, Keller M, Weber T. Acute ovarian torsion in children. Am. J. Surg. 2000;180:462-5. Oltmann SC, Fischer A, Barber R, Huang R, Hicks B, Garcia N. Cannot exclude torsion – a 15-year review. J. Pediatr. Surg. 2009;44:1212-6; discussion 1217. Chmitt ER et al. Twist and Shout! Pediatric Ovarian Torsion Clinical Update and Case Discussion. Pediatr Emerg Care. 2013; 29(4):518-523. Servaes S, Zurakowski D, Laufer MR, Feins N, Chow JS. Sonographic findings of ovarian torsion in children. Pediatr. Radiol. 2007;37:446-51. Epub 2007 Mar 15. Valsky DV. Added value of the gray-scale whirlpool sign in the diagnosis of adnexal torsion. Ultrasound Obstet. Gynecol. 2010;36:630-4.

Children the world over are fascinated with what can possibly “fit” in their orifices.  Diagnosis is often delayed.  Anxiety abounds before and during evaluation and management.     Most common objects:1,2 Food Coins Toys Insects Balls, marbles Balloons Magnets Crayon Hair accessories, bows Beads Pebbles Erasers Pen/marker caps Button batteries Plastic bags, packaging Non-pharmacologic techniques Set the scene and control the environment.  Limit the number of people in the room, the noise level, and minimize “cross-talk”.  The focus should be on engaging, calming, and distracting the child. Quiet room; calm parent; “burrito wrap”; guided imagery; have a willing parent restrain the child in his or her lap – an assistant can further restrain the head. Procedural Sedation Most foreign bodies in the ear, nose, and throat in children can be managed with non-pharmacologic techniques, topical aids, gentle patient protective restraint, and a quick hand.  Consider sedation in children with special health care needs who may not be able to cooperate and technically delicate extractions.  Ketamine is an excellent agent, as airway reflexes are maintained.3  Remember to plan, think ahead: where could the foreign body may be displaced if something goes wrong?  You may have taken away his protective gag reflex with sedation.  Position the child accordingly to prevent precipitous foreign body aspiration or occlusion. L’OREILLE – DAS OHR – вухо – THE EAR – LA OREJA – 耳 – L'ORECCHIO Essential anatomy: The external auditory canal. Foreign bodies may become lodged in the narrowing at the bony cartilaginous junction.4  The lateral 1/3 of the canal is flexible, while the medial 2/3 is fixed in the temporal bone – here is where many foreign bodies are lodged and/or where the clinician may find evidence of trauma.  Pearls: Ask yourself: is it graspable or non-graspable?5 Graspable: 64% success rate, 14% complication rate Non-graspable: 45% success rate, 70% complication rate5 If there is an insect in the external auditory canal, kill it first. They will fight for their lives if you try to dismember or take them out.  “In the heat of battle, the patient can become terrorized by the noise and pain and the instrument that you are using is likely to damage the ear canal.”5,6  Use lidocaine jelly (preferred), viscous lidocaine (2%), lidocaine solution (2 or 4%), isopropyl alcohol, or mineral oil. Vegetable matter? Don’t irrigate it – the organic material will swell against the fixed structure, and cause more pain, make it much harder to extract, and may increase the risk of infection. Pifalls: Failure to inspect after removal – is there something else in there? Failure to assess for abrasions, trauma, infection – if any break in skin, give prophylactic antibiotic ear drops Law of diminishing returns: probability of successful removal of ear foreign bodies declines dramatically after the first attempt   LE NEZ – DIE NASE – ніс – THE NOSE – LA NARIZ – 鼻 – IL NASO Essential anatomy: Nasopharyngeal and tracheal anatomy. Highlighted areas indicate points at which nasal foreign bodies may become lodged.4 Pearls: Consider using topical analgesics and vasoconstrictors to reduce pain and swelling – and improve tolerance of/cooperation with the procedure. Use 0.5% oxymetolazone (Afrin) spray and a few drops of 2 or 4%   Pros: as above.  Cons: possible posterior displacement of the foreign body.7 Be ready for the precipitous development of an airway foreign body Pitfalls: Beware of unilateral nasal discharge in a child – strongly consider retained foreign body.8 Do not push a foreign body down the back of a patient's throat, where it may be aspirated into the trachea. Be sure to inspect the palate for “vacuum effect”: small or flexible objects may be found on the roof of the mouth, just waiting to be aspirated.   LA GORGE – DER HALS – горло – THE THROAT – LA GARGANTA – 喉 – LA GOLA Before we go further – Remember that a foreign body in the mouth or throat can precipitously become a foreign body in the airway.  Foreign body inhalation is the most common cause of accidental death in children less than one year of age.9,10 Go to BLS maneuvers if the child decompensates. Infants under 1 year of age – back blows: head-down, 5 back-blows (between scapulae), 5 chest-thrusts (sternum).  Reassess, repeat as needed. Children 1 year and up, conscious – Heimlich maneuver: stand behind patient with arms positioned under the patient’s axilla and encircling the chest. The thumb side of one fist should be placed on the abdomen below the xiphoid process. The other hand should be placed over the fist, and 5 upward-inward thrusts should be performed. This maneuver should be repeated if the airway remains obstructed.  Alternatively, if patient is supine, open the airway, and if the object is readily visible, remove it.  Abdominal thrusts: place the heel of one hand below the xiphoid, interlace fingers, and use sharp, forceful thrusts to dislodge.  Be ready to perform CPR. Children 1 year and up, unconscious – CPR: start CPR with chest compressions (do not perform a pulse check). After 30 chest compressions, open the airway. If you see a foreign body, remove it but do not perform blind finger sweeps because they may push obstructing objects further into the pharynx and may damage the oropharynx.  Attempt to give 2 breaths and continue with cycles of chest compressions and ventilations until the object is expelled. Chest films are limited: 80% of airway foreign bodies are radiolucent.11  Look for unilateral hyperinflation on expiratory films: air trapping.  Essential anatomy: Most esophageal foreign bodies in children occur at the level of the thoracic inlet / cricopharyngeus muscle (upper esophageal sphincter).  Other anatomically narrow sites include the level of the aortic arch and the lower esophageal sphincter. Coin en face – in the esophagus – lodged at the thoracic inlet.12  The pliable esophagus accommodates the flat coin against the flat aspect of the vertebra.11 Beware the “double-ring” sign: this is a button battery13 This is an emergency: the electrolyte-rich mucosa conducts a focal current from the narrow negative terminal of the battery, rapidly causing burn, necrosis, and possibly perforation.  Emergent removal is required. Button batteries that have passed into the stomach do not require emergent intervention – they can be followed closely. Not a button battery, not a sharp object, not a long object? If there is no obstruction, consider revaluation the next day – may wait up to 24 hours for passage.14  Sharieff et al.15 found that coins found in the mid to distal esophagus within 24 hours all passed successfully. What conditions prompt urgent removal? Size Infants: objects smaller than 2 cm wide and 3 cm long will likely pass the pylorus and ileocecal valve10 Children and adults: objects smaller than 2 cm wide and 5 cm long will likely pass the pylorus and ileocecal valve9 Character Sharp objects have a high rate of perforation (35%)1 Pearls: History is essential. Believe the parents and assume there is an aspirated/ingested foreign body until proven otherwise. History of choking, has persistent symptoms and/or abnormal xray? Broncoscopy! Cohen et al.16 found that of 142 patients evaluated at a single site university hospital, 61 had a foreign body. Of the 61 patients, 42 had abnormal physical exams and radiographs and 17 had either abnormal physical exams or radiographs, and 2 had normal physical exams and radiographs, but both had a history of persistent cough.  Bottom line: history of choking PLUS abnormal exam, abnormal films, or persistent symptoms, evaluate with bronchoscopy. For patients with some residual suspicion of an aspirated foreign body (mild initial or improving symptoms; possibly abnormal chest x-ray; low but finite risk), consider chest CT with virtual bronchoscopy as a rule-out strategy.17,18 Outpatients who have passed a small and non-concerning object into the stomach or beyond: serial exams and observing stools – polyethylene glycol 3350 (MiraLAX) may be given for delayed passage19 Pifalls: A single household magnet will likely pass through the GI tract, with the aforementioned dimensional caveats. Two or more magnets, however, run the risk of attraction and trans-bowel wall pressure necrosis. Not all magnets are created equal. Neodymium magnet toys (“buckyballs”) were recalled in 2014 (but are still out there!) due to their highly attractive nature.  These magnets must be removed to avoid bowel wall ischemia. 19–21 Patients should avoid wearing belt buckles or metallic buttons in case of single magnet ingestion while waiting for the single magnet to pass DES OUTILS DU MÉTIER – DIE HANDWERKSZEUG – Знаряддя праці – TOOLS OF THE TRADE – LAS HERRAMIENTAS DEL OFICIO – GLI ATTREZZI DEL MESTIERE –  仕事のツール It’s best to keep your armamentarium as large as you can.   Curette A small foreign body in the lateral 1/3 of the auditory canal may be amenable to a simple curettage.  Hair beads (if the central hole is accessible) may be manipulated out with the angled tip of a rigid curette.  Steady the operating hand by placing your hypothenar eminence on the child’s zygoma or temporal scalp, to avoid jutting the instrument into the ear canal with sudden movement.  There is a large selection of disposable simple and lighted curettes on the market. Right-angle Hook Various eponymous hooks are available for this purpose; one in popular use is the Day hook, which may be passed behind the foreign body.22  An inexpensive and convenient alternative to the commercially available right-hooks is a home-made version: make your own by straightening out a paperclip and bending it to a right angle23 at 2-3 mm from the end (be sure not to use the type that have a friable shiny metallic finish, as the residue may be left behind in the ear canal).  If it is completely lodged, use of a right-angle hook will likely only cause trauma to the canal. Alligator forceps Alligator forceps are best for grasping soft objects like cotton or paper.  Smooth, round or oval objects are not amenable to extraction with alligator forceps.  When using them, be sure to get a firm, central grip on the object, to avoid tearing it into smaller, less manageable pieces.  Pro tip: Look before you grip! Be careful to visualize the area you are gripping, to avoid pulling on (and subsequently avulsing) soft tissue in the ear canal. Cyanoacrylate (Dermabond®, SurgiSeal®) Apply cyanoacrylate to either side of a long wooden cotton swab (the lecturer prefers the cotton tip side, for improved grip/molding around object).  Immediately apply the treated side to the object in the ear canal in a restrained patient.  Steady the hypothenar eminence on the child’s face to avoid dislodgement of the cotton swab with sudden movement.  Apply the treated swab to the foreign body for 30-60 seconds, to allow bonding.  Slowly pull out the foreign body.  Re-visualize the ear canal for other retained foreign bodies and abrasion or ear canal trauma. Did the cyanoacrylate drip?  Did the swab stick to the ear canal? No problem – use 3% hydrogen peroxide or acetone.24  Pour in a sufficient amount, allow to work for 10 minutes.  Both agents help to dissolve ear wax, the compound, or both.  Repeat if needed to debond the cyanoacrylate from the ear canal.24,25 Irrigation Irrigation is the default for non-organic foreign bodies that are not amenable to other extraction techniques.  Sometimes the object is encased in cerumen, and the only “instrument” that will fit behind the foreign body is the slowly growing trickle of water that builds enough pressure to expulse it.  Do not use if there is any organic material involved: the object will swell, causing much more pain, difficulty in extraction, and possibly setting up conditions for infection. Position the child either prone or supine, gently restrain (as above).  Let gravity work for you: don’t irrigate in decubitus position with the affected ear up.  It may be more accessible to you, but you may never get the foreign body out. To use a butterfly needle: use a small gage (22 or 24 g) butterfly set up, cut off the needle, connect the tubing to a 30 mL syringe filled with warm or room-temperature water. Insert the free end of the tubing gently, and “secure” the tubing with your pinched fingers while irrigating (think of holding an ETT in place just after intubation and before taping/securing the tube).  Gently and slowly increase the pressure you exert as you irrigate. To use an IV or angiocatheter: use a moderate size (18 or 20 g) IV, remove the needle and attach the plastic catheter to a 20 mL syringe, and irrigate as above. Acetone Acetone has been used successfully to remove chewing gum, Styrofoam, and superglue from the ear canal24,26,27  Use in cases where there is no suspicion of perforation of the tympanic membrane. Docusate Sodium (Colace®) Cerumen is composed of sebaceous ad ceruminous secretions and desquamated skin.  Genetic, environmental, and anatomical factors combine to trap a foreign body in the external canal.  Use of a ceruminolytic such as docusate sodium may help to loosen and liberate the foreign body.28  Caveat medicus: Adding docusate sodium will make the object more slippery – this may or may not be an issue given the nature of the foreign body. In the case where loosening the ear wax may aid extraction (and will not cause a slippery mess), consider filling the ear canal will docusate sodium (Colace), having the child lie with the affected side up, waiting 15 minutes, and proceeding.  This is especially helpful when planning for irrigation. Magnets Rare earth magnets (a misnomer, as their components are actually abundant) such as neodymium can be useful in retrieving metallic foreign bodies (e.g. button batteries in the nose or ears).29,30  Magnetic “pick-up tools” – used by mechanics, engineers, and do-it-yourselfers – are inexpensive and readily available in various sizes, shapes, and styles such as a telescoping extender.  Look for a small tip diameter (to fit in the ear canal as well as the nose) and a strong “hold” (at least a 3-lb hold). Alternatively, you may purchase a strong neodymium bar magnet (30- to 50-lb hold) to attach to an instrument such as an alligator forceps, pick-up forceps, or small hemostat (a pacemaker magnet may also work).  The magnetic bar, placed in your palm at the base of the instrument, will conduct the charge (depending on the instrument) and allow you to retrieve many metallic objects.31  Although stainless steel is often said to be “non-magnetic”, it depends on the alloy used, and some may actually respond to the strong rare earth magnet.  Most stainless steel has a minimum of 10.5% chromium, which gives the steel its 'stainless' properties (essentially corrosion resistance).  A basic stainless steel has a “ferritic” structure and is magnetic.  Higher-end stainless steel such as in kitchen cutlery have an “austenitic” structure, with more chromium added, and so less magnetic quality.  (Ironically, the more “economical” instruments in the typical ED suture kit have less chromium, and so are more magnetic – use these with your neodymium bar magnet to conduct the magnetic charge and extract the metallic foreign body.) Bottom line: if it’s metal, it’s worth a try to use a magnet.  Even if the metal is very weakly magnetic, the strong neodymium magnet may still be able to exert a pull on it and aid in extraction. Snare Technique A relatively new method, described by Fundakowski et al.32 consists of using a small length of 24-gauge (or similar) wire (available inexpensively online, and kept in your personal “toolkit”; see Appendix B below) to make a loop that is secured by a hemostat (the 24-gauge wire is easily cut into strips with standard trauma scissors).  After treatment with oxymetolazone (0.05%) and lidocaine (1 or 2%) topically, the loop is passed behind the foreign body (in the case report, a button battery).  Pull the loop toward you until you feel that it is sitting up against the button battery.  Now, turn the hemostat 90° to improve your purchase on the foreign body.  Pull gently out.  This technique is especially useful when the foreign body has created marked edema, either creating a vacuum effect or making it difficult for other instruments to pass. Balloon Catheters (Katz extractor®, Fogarty embolectomy catheter) Small-caliber devices (5, 6, or 8 F) originally designed for use with intravascular or bladder catheterization may be used to extract foreign bodies from the ear or nose.7,33  A catheter designed specifically for foreign body use is the Katz extractor.  Inspect the ear or nose for potential trauma and to anticipate bleeding after manipulation (especially the nose).  Deflate the catheter and apply surgical lubricant or 2% lidocaine jelly. Insert the deflated catheter and gently pass the device past the foreign body.  Inflate the balloon and slowly pull the balloon and foreign body out.  Re-inspect after extraction. NB, from the manufacturer of the Katz extractor, InHealth: “the Katz Extractor oto-rhino foreign body remover is intended principally for extraction of impacted foreign bodies in the nasal passages. This device may also be used in the external ear canal, based upon clinical judgment.” Mother’s kiss The mother’s kiss was first described in 1965 by Vladimir Ctibor, a general practitioner from New Jersey.34 “The mother, or other trusted adult, places her mouth over the child’s open mouth, forming a firm seal as if about to perform mouth-to-mouth resuscitation. While occluding the unaffected nostril with a finger, the adult then blows until feeling resistance caused by closure of the child’s glottis, at which point the adult gives a sharp exhalation to deliver a short puff of air into the child’s mouth. This puff of air passes through the nasopharynx, out through the non-occluded nostril and, if successful, results in the expulsion of the foreign body. The procedure is fully explained to the adult before starting, and the child is told that the parent will give him or her a “big kiss” so that minimal distress is caused to the child. The procedure can be repeated a number of times if not initially successful.”34 Positive Pressure Ventilation with Bag Valve Mask This technique is an approximation of the above mother’s kiss technique – useful for unwilling parents or unsuccessful tries.10,25  The author prefers to position the child sitting up.  A self-inflating bag-mask device is fitted with a very small mask: use an abnormally small mask (otherwise inappropriately small for usual resuscitative bag-mask ventilation) to fit over the mouth only.  Choose an infant mask that will cover the child’s mouth only.  Occlude the opposite nostril with your finger while you form a tight seal with the mask around the mouth. Deliver short, abrupt bursts of ventilation through the mouth – be sure to maintain good seals with the mask and with your finger to the child’s nostril – until the foreign body is expulsed through the affected nostril. Beamsley Blaster (Continuous Positive Pressure) Technique For the very uncooperative child with a nasal foreign body amenable to positive pressure ventilation who fails the mother’s kiss and bag-mask technique, a continuous positive pressure method may be used. Connect one end of suction tubing to the male adaptor (“Christmas tree”) of an air or oxygen source.  Connect the other end of the suction tubing to a male-to-male adaptor (commonly used for chest tube connections or connecting / extending suction tubes).  Insert the end of the device into the child’s unaffected nostril.  The air flow will deliver positive pressure ventilation continuously. With this technique there is a theoretical risk of barotrauma to the lungs or tympanic membranes.  However, there is only one case reported in the literature of periorbital subcutaneous emphysema. To minimize this risk, some authors recommend limiting to a maximum of four attempts using any positive pressure method.10 Nasal speculum Optimize your visualization with a nasal speculum.  The nostrils, luckily, will accommodate a fair amount of distention without damage.  Hold the speculum vertically to avoid pressure on and damage to the vessel-and-nerve-rich nasal septum.  Hold the handle of the speculum in the palm of your hand comfortably and while placing your index finger on the patient’s ala.  This will help to control the speculum and your angle of sight. Your other hand is then free to use a hook or other tool for extraction. Lighting is especially important when using the nasal speculum: a focused procedure light or head lamp is very helpful.  The author keeps a common camping LED headlamp in his bag for easy access. Suction tips / catheters Various commercial and non-commercial suction devices are on the market for removal of foreign bodies.  All connect to wall suction, and vary by style, caliber of suction, and tip end interface.  A commonly available suction catheter is the Frazier suction tip (right), a single-use device used in the operating room. A modification to suction can be made with the Schuknecht foreign body remover (left; not to be confused with the suction catheter of the same name): a plastic cone-shaped tip placed on the end of the suction catheter to increase vacuum surface area and seal.  Laryngoscope and Magill Forceps If a child aspirates and occludes his airway, return to BLS maneuvers (as above).  If the child becomes obtunded, use direct laryngoscopy to visualize the foreign body and remove with the Magill forceps.  Hold the laryngoscope in your left hand as per usual.  Hold the Magill forceps in your right hand – palm side down – to grasp and remove the foreign body.  Take-home Points  Beware the “vacuum palate”: a flat (especially clear plastic) foreign body hiding on the palate Take seriously the complaint of foreign body without obvious evidence on initial inspection – believe that something is in there until proven otherwise Control the environment, address analgesia and anxiolysis, have a back-up plan Motto Like a difficult airway: plan through the steps MERCI – DANKE – Дякую – THANK YOU – GRACIAS –  ありがとう— GRAZIE Appendix A: Prevention At the end of the visit, after some rapport has been established, counsel the caregivers about age-appropriate foods and “child-proofing” the home.  This is a teachable moment – and only you can have this golden opportunity! Age-appropriate foods 0-6 months: breastmilk or formula 6-9 months: introduce solid puree-consistency foods 9-12 months: small minced solids that require no chewing (well cooked, soft, chopped foods) Although molars (required for chewing) erupt around 18 months, toddlers need to develop coordination, awareness to eat hard foods that require considerable chewing. Not until 4 years of age (anything that requires chewing to swallow):             Hot dogs             Nuts and seeds             Chunks of meat or cheese             Whole grapes             Hard or sticky candy             Popcorn             Chunks of peanut butter             Chunks of raw vegetables             Chewing gum Child-proofing the home Refer parents to the helpful multi-lingual site from the American Academy of Pediatrics: http://www.healthychildren.org/English/safety-prevention/at-home/Pages/Childproofing-Your-Home.aspx An abbreviated list: use age-appropriate toys and “test” them out before giving them to your child to verify that there are no small, missing, or loose parts.  Secure medications, lock up cabinets (especially with chemicals), do not store chemicals in food containers, secure the toilet bowl, and unplug appliances. Parents should understand that “watching” their child alone cannot prevent foreign body aspiration: a recent review found that in 84.2% of cases, incidents resulting in an airway foreign body occurred in the presence of an adult.35 Best overall tip: get down on all fours and inspect your living area from the child’s perspective.  It is amazing what you will find when you are least expecting it. Appendix B: The Playbook's ENT Foreign Body Toolkit Although your institution should supply you with what you need to deal with routine problems, we all struggle with having just what we need when we need it.  High-volume disposable items such as cyanoacrylate (Dermabond), curettes, supplies for irrigation, alligator forceps, and the like certainly should be supplied by the institution.  However, some things come in very handy as our back-up tools. NB: we should be cognizant of the fact that tools that must be sterilized or autoclaved are not good candidates for our personal re-usable toolkits. These items can all be found inexpensively – shop around online, or in home improvement stores: Head lamp, LED camping style: $5-15 Neodymium magnet “pick-up tool”: $5-15 Neodymium bar magnet: $6-20 Wire, 24-gauge, spool of 25 yards (for snare technique): $6 Day hook: $15-20 References Chapin MM, Rochette LM, Annest JL, Haileyesus T, Conner KA, Smith GA. Nonfatal Choking on Food Among Children 14 Years or Younger in the United States, 2001–2009. Pediatrics. 2013;132(2):275-281. doi:10.1542/peds.2013-0260. Committee on Injury V. Policy Statement—Prevention of Choking Among Children. Pediatrics. 2010:peds.2009-2862. doi:10.1542/peds.2009-2862. Brown L, Denmark TK, Wittlake WA, Vargas EJ, Watson T, Crabb JW. Procedural sedation use in the ED: management of pediatric ear and nose foreign bodies. Am J Emerg Med. 2004;22(4):310-314. Heim SW, Maughan KL. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007;76(8):1185-1189. DiMuzio J, Deschler DG. Emergency department management of foreign bodies of the external ear canal in children. Otol Neurotol Off Publ Am Otol Soc Am Neurotol Soc Eur Acad Otol Neurotol. 2002;23(4):473-475. Leffler S, Cheney P, Tandberg D. Chemical immobilization and killing of intra-aural roaches: an in vitro comparative study. Ann Emerg Med. 1993;22(12):1795-1798. Kiger JR, Brenkert TE, Losek JD. Nasal foreign body removal in children. Pediatr Emerg Care. 2008;24(11):785-792; quiz 790-792. doi:10.1097/PEC.0b013e31818c2cb9. Kadish HA, Corneli HM. Removal of nasal foreign bodies in the pediatric population. Am J Emerg Med. 1997;15(1):54-56. Tahir N, Ramsden WH, Stringer MD. Tracheobronchial anatomy and the distribution of inhaled foreign bodies in children. Eur J Pediatr. 2009;168(3):289-295. doi:10.1007/s00431-008-0751-9. Rempe B, Iskyan K, Aloi M. An Evidence-Based Review of Pediatric Retained Foreign Bodies. Pediatr Emerg Med Pract. 6(12). Digoy GP. Diagnosis and management of upper aerodigestive tract foreign bodies. Otolaryngol Clin North Am. 2008;41(3):485-496, vii - viii. doi:10.1016/j.otc.2008.01.013. Loren Yamamoto, Inaba A, DiMauro R. Radiologic Cases in Pediatric Emergency Medicine; University of Hawaii. Radiol Cases Emerg Med. http://www.hawaii.edu/medicine/pediatrics/pemxray/zindex.html. Accessed February 20, 2015. Painter K. Energizer makes button battery packages safer for kids. USA Today. ASGE Standards of Practice Committee, Ikenberry SO, Jue TL, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091. doi:10.1016/j.gie.2010.11.010. Sharieff GQ, Brousseau TJ, Bradshaw JA, Shad JA. Acute esophageal coin ingestions: is immediate removal necessary? Pediatr Radiol. 2003;33(12):859-863. doi:10.1007/s00247-003-1032-4. Cohen S, Avital A, Godfrey S, Gross M, Kerem E, Springer C. Suspected Foreign Body Inhalation in Children: What Are the Indications for Bronchoscopy? J Pediatr. 2009;155(2):276-280. doi:10.1016/j.jpeds.2009.02.040. Haliloglu M, Ciftci AO, Oto A, et al. CT virtual bronchoscopy in the evaluation of children with suspected foreign body aspiration. Eur J Radiol. 2003;48(2):188-192. doi:10.1016/S0720-048X(02)00295-4. Jung SY, Pae SY, Chung SM, Kim HS. Three-dimensional CT with virtual bronchoscopy: a useful modality for bronchial foreign bodies in pediatric patients. Eur Arch Otorhinolaryngol. 2011;269(1):223-228. doi:10.1007/s00405-011-1567-1. Hussain SZ, Bousvaros A, Gilger M, et al. Management of ingested magnets in children. J Pediatr Gastroenterol Nutr. 2012;55(3):239-242. doi:10.1097/MPG.0b013e3182687be0. Brown JC, Otjen JP, Drugas GT. Too attractive: the growing problem of magnet ingestions in children. Pediatr Emerg Care. 2013;29(11):1170-1174. doi:10.1097/PEC.0b013e3182a9e7aa. Brown JC, Otjen JP, Drugas GT. Pediatric magnet ingestions: the dark side of the force. Am J Surg. 2014;207(5):754-759; discussion 759. doi:10.1016/j.amjsurg.2013.12.028. Menner AL. Pocket Guide to the Ear: A Concise Clinical Text on the Ear and Its Disorders. Thieme; 2011. Colina D, Dudek S, Lin M. Tricks of the Trade: ENT Dilemmas - How Do I Get That Out of There? ACEP News. http://www.acep.org/Clinical---Practice-Management/Tricks-of-the-Trade--ENT-Dilemmas---How-Do-I-Get-That-Out-of-There-/?__taxonomyid=118010. Published July 2009. Accessed February 5, 2015. Abadir WF, Nakhla V, Chong P. Removal of superglue from the external ear using acetone: case report and literature review. J Laryngol Otol. 1995;109(12):1219-1221. Kadish H. Ear and Nose Foreign Bodies “It is all about the tools.” Clin Pediatr (Phila). 2005;44(8):665-670. doi:10.1177/000992280504400803. Chisholm EJ, Barber-Craig H, Farrell R. Chewing gum removal from the ear using acetone. J Laryngol Otol. 2003;117(4):325. doi:10.1258/00222150360600995. White SJ, Broner S. The use of acetone to dissolve a Styrofoam impaction of the ear. Ann Emerg Med. 1994;23(3):580-582. Singer AJ, Sauris E, Viccellio AW. Ceruminolytic effects of docusate sodium: a randomized, controlled trial. Ann Emerg Med. 2000;36(3):228-232. doi:10.1067/mem.2000.109166. Bledsoe RD. Magnetically adherent nasal foreign bodies: a novel method of removal and case series. Am J Emerg Med. 2008;26(7):839.e1-e839.e2. doi:10.1016/j.ajem.2008.01.036. Dolderer JH, Kelly JL, Morrison WA, Penington AJ. FOREIGN-BODY RETRIEVAL USING A RARE EARTH MAGNET: Plast Reconstr Surg. 2004;113(6):1869-1870. doi:10.1097/01.PRS.0000119869.01081.1C. Yeh B, Roberson JR. Nasal magnetic foreign body: a sticky topic. J Emerg Med. 2012;43(2):319-321. doi:10.1016/j.jemermed.2010.02.013. Fundakowski CE, Moon S, Torres L. The snare technique: a novel atraumatic method for the removal of difficult nasal foreign bodies. J Emerg Med. 2013;44(1):104-106. doi:10.1016/j.jemermed.2012.07.070. Chan TC, Ufberg J, Harrigan RA, Vilke GM. Nasal foreign body removal. J Emerg Med. 2004;26(4):441-445. doi:10.1016/j.jemermed.2003.12.024. Cook S, Burton M, Glasziou P. Efficacy and safety of the “mother’s kiss” technique: a systematic review of case reports and case series. Can Med Assoc J. 2012;184(17):E904-E912. doi:10.1503/cmaj.111864. Gregori D, Morra B, Snidero S, et al. Foreign bodies in the upper airways: the experience of two Italian hospitals. J Prev Med Hyg. 2007;48(1):24-26. This post and podcast are dedicated to Linda Dykes, MBBS(Hons) for her can-do attitude and collaborative spirit.  Thank you for sharing your knowledge, experience, and heart with the world.

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

N.B.: This month's show notes are a departure from the usual summary.  Below is a reprint (with permission) of a soon-to-be released chapter, Horeczko T. "Acute Pain in Children". In Management of Pain and Procedural Sedation in Acute Care. Strayer R, Motov S, Nelson L (eds). 2017.  Rather than the customary blog post summary, the full chapter (with links) is provided as a virtual reference. INTRODUCTION Pain is multifactorial: it is comprised of physical, psychological, emotional, cultural, and contextual features.  In children often the predominant feature may not be initially apparent.  Although clinicians may focus on the physical component of pain, much time, energy, and suffering can be saved through a holistic approach.  What is the age and developmental stage of the child?  How is the child reacting to his condition?  What are the circumstances?  What is the family or caregiver dynamic? We rely much on how patients and families interact with us to gauge pain.  Assessing and managing children’s pain can be challenging, because they may not exhibit typically recognized signs and symptoms (Srouji 2010).  Further, children participate in and absorb their family’s culture and specific personality from a very young age (Finley 2009).  Knowing the context of the episode may help.  For example, a very anxious caregiver can easily transmit his or her anxiety to the child, which may either inhibit or amplify presentation of symptoms (Bearden 2012). The guiding principles in pediatric pain assessment and management are: know the child; know the family; and know the physiology.  Children have long suffered from an under-treatment of their pain, due both to our incomplete acknowledgement of their pain and our fear of treatment (Howard 2003).  As the pendulum on pain management swings one way or the other, do not let your pediatric patient get knocked by the wayside.  Take a thoughtful approach: know the signs and symptoms, and aggressively treat and reassess. ASSESSMENT Each stage of development offers a unique framework to the child’s signs and symptoms of pain.  In pre-verbal children, use your observational skills in addition to the parent’s report of behavior.  Verbal children can self-report; younger children require pictorial descriptions, while older children and adolescents may use standard adult scales.  In all ages, ask open-ended questions and allow the child to report and speak for himself whenever possible. Neonates Neonates are a unique group in pain assessment.  The neonate (birth to one month of age) has not yet acquired social expression of pain, and his nascent nervous system is only now learning to process it.  Do not expect typical pain behaviors in neonates.  Facial grimacing is a weak indicator of pain in neonates (Liebelt 2000).  When this behavior is present, look for a furrowed brow, eyes squeezed shut, and a vertically open mouth.  Tachycardia, tachypnea, and a change in behavior can be indicators not only to the presence of pain, but possibly to its etiology as well. Neonatal observational scales have been validated in the intensive care and post-operative settings; ED-specific quantitative scales are lacking.  CRIES is a 10-point scale, using a physiologic basis similar to APGAR: Crying; Requires increased oxygen administration (distress and breath-holding); Increased vital signs; Expression; and Sleeplessness (Krechel 1995).  CRIES (Table 1) was validated for post-operative patients; to adapt its use for the ED, the most conservative approach is to substitute “preoperative baseline” with normal range for age.  Although the numerical values of CRIES have not been validated to date in the ED, the clinician may find the domains included in CRIES to be a useful cognitive construct in assessing neonatal pain. Neonatal pain pathways are particularly plastic; prompt assessment of and increased alertness to neonatal pain may help to mitigate long-lived pain sensitivity and hyperalgesia (Taddio 2002).  In other words, treat the neonate’s pain seriously, as you may save him long-term pain sequelae in the future. Infants and Toddlers This group will begin to exhibit more reproducible, reliable signs and symptoms of pain. For infants of less than one year of age, the Neonatal Infant Pain Scale (NIPS) uses observational and physiologic parameters to detect pain (Table 2).  A score of 0-2 indicates no pain present.  A score of 3-4 indicates mild to moderate pain; non-pharmacologic techniques may be tried first.  A score of 5 or greater indicates severe pain; some pharmacologic intervention is indicated (Lawrence 1993). For children greater than one year who are preverbal, a well performing scale is the FLACC score: Face, Legs, Activity, Cry, Consolability (Table 3). Contextual and caregiver features predominate in this group.  Frequent reassessments are helpful, as the initial trepidation and fright in triage may not accurately reflect the child’s overall pain status. Preschool and School-age children Increasing language development offers the hope of more information to the clinician, but be careful not to ask leading questions.  Do not jump directly to “does this hurt?”.  Preschoolers will say ‘yes’ to anything, in an attempt to please you.  School-age children may passively affirm your “statement”, if only to validate their human need for care or attention.  Start with some ice-breaking banter, lay down the foundations for rapport, and then ask open-ended questions.  Be careful not to allow the caregiver to “instruct” the child to tell you where it hurts, how much, how often, etc.  Rather, engage the parents by asking them what behavior they have noticed.  Eliciting history from both the child and the parent will go a long way in constructing a richer picture of the etiology and severity of the pain, and will help to build rapport and trust. The Baker-Wong FACES Pain Rating scale (Figure 1) was developed with feedback from children and has been validated for use in those 3 years of age and older (Keck 1996, Tomlinson 2010). Adolescents Adolescents vary in their development, maturity, and coping mechanisms.  You may see a mixture of childhood and adult behaviors in the same patient; e.g. he may be initially stoic or evades questioning, then later exhibits pseudo-inconsolability.  Do what you can to see the visit from the adolescent’s perspective, and actively transmit your concern and intention to help – many will respond to a warm, open, non-judgemental, and helpful attitude.  The overly “tough” adolescent is likely secretly fearful, and the “dramatic” adolescent may simply be very anxious.  Take a moment to gauge the background behind the presentation. You may use the typical adult scale of 0 (no pain) to 10 (worst pain), or the Faces Pain Scale–Revised (FPS-R).  The FPS-R uses more neutral and realistic faces and, unlike the Wong Baker scale, does not use smiling or crying faces to anchor the extremes of pain (Tsze 2013). PAIN PHYSIOLOGY Pain includes two major components: generation and perception.  Generation of pain involves the actual propagation of painful stimuli, either through nociceptive pain or neuropathic pain.  Nociceptive pain arises from free nerve endings responding to tissue damage or inflammation. Nociceptive pain follows a specific sequence: transduction (an action potential triggered by chemical mediators in the tissue, such as prostaglandins, histamine, bradykinin, and substance P); transmission (the movement of the action potential signal along the nerve fibers to the spinal cord); perception (the impulse travels up the spinothalamic tract to the thalamus and midbrain, where input is splayed out to the limbic system, somatosensory cortex, and parietal and frontal lobes); and modulation (the midbrain enlists endorphins, enkephalins, dynorphin, and serotonin to mitigate pain) (Pasero 2011).  As clinicians we can target specific “stations” along the pain route to target the signal more effectively. Simple actions such as ice, elevation, local anesthetics, or splinting help in pain transduction.  Various standard oral, intranasal, or IV analgesics may help with pain’s transmission. Non-pharmacologic techniques such as distraction, re-framing, and others can help with pain perception.  The sum of these efforts encourage pain modulation. A phenomenon separate from nociceptive pain is neuropathic pain, the abnormal processing of pain stimuli.  It is a dysregulated, chaotic process that is difficult to manage in any setting.  Separating nociceptive from neuropathic symptoms may help to select specific pain treatments and to clarify treatment goals and expectations. Neonates Neonates are exquisitely sensitive to many analgesics.  Hepatic enzymes are immature and exhibit decreased clearance and prolonged circulating levels of the drug administered.  Once the pain is controlled, less frequent administration of medications, with frequent reassessments, are indicated. The neonate’s vital organs (brain, heart, viscera) make up a larger proportion of his body mass than do muscle and fat.  That is to say, the volume of distribution is unique in a neonate.  Water-soluble drugs (e.g. morphine) reach these highly perfused vital organs quickly; relatively small overdosing will have rapid and exaggerated central nervous system and cardiac effects.  The neonate’s small fat stores and muscle mass limit the volume of distribution of lipophilic medications (e.g. fentanyl, meperidine), also making them more available to the central nervous system, and therefore more potent.  Other factors that predispose neonates to accidental analgesic overdose are their decreased concentrations of albumin and other plasma proteins, causing a higher proportion of unbound drug.  Renal clearance is also decreased in the first few months of life. Clinical note: in the ED, neonates often require analgesia for procedures more than for injury.  Non-pharmacologic techniques predominate (see below).  Make liberal use of local anesthetics such as eutectic mixture of local anesthetics (EMLA; for intact skin, e.g. IV access, lumbar puncture) and lidocaine-epinephrine-tetracaine gel (LET; for superficial open skin and soft tissue application).  Oral sucrose (30%) solutions (administered either with a small-volume syringe or pacifier frequently dipped in solution) are effective for minor procedures (Harrison 2010, Stevens 2013) via the release of dopamine and through distraction by mechanical means.  Neonates with severe pain may be managed with parenteral analgesics, on a monitor, and with caution. Infants and Toddlers With increasing body mass comprised of fat stores in conjunction with an increase in metabolism, this group will require a different approach than the neonate.  For many medications, these children will have a greater weight-normalized clearance than adults (Berde 2002).  They will often require more frequent dosing.  Infants and toddlers have a larger functioning liver mass per kilogram of body weight, with implications for medications cleared by cytochrome p-450. Clinical note: some drugs, such as benzodiazepines, will have both a per-kilogram dosing as well as an age-specific modification.  When giving analgesics or anxiolytics to young children, always consult a reference for proper dosing and frequency. School-age children and Adolescents This group retains some hyper-metabolic features of younger children, but the dose-effect relationship is more linear and transparent.  Physiologic clearance is improved, and from a physical standpoint, these are typically lower-risk children.  From a psychological standpoint, this group may need more non-pharmacologic consideration and support to modulate pain optimally. NON-PHARMACOLOGIC TREATMENT The first line of treatment in all pain management is non-pharmacopeia (Horeczko 2016).  Not only is this the safest of all techniques, but often the most effective.  Some are simple comfort measures such as splinting (fracture or sprain), applying cold (acute soft tissue injury) or heat (non-traumatic, non-specific pain), or other targeted non-pharmacology. Many a pain control regimen is sabotaged without consideration of non-pharmacologic techniques, which may augment, or at times replace, analgesics.  Think of non-pharmacopoeia as your “base coat” or “primer” before applying additional coats of analgesic treatment.  With the right base coat foundation, you have a better chance of painting a patient’s symptoms a more tolerable and long-lasting new color. A tailored approach based on age will allow the practitioner to employ a child’s developmental strengths and avoid the frustration that results in asking the child to do what he is not capable of doing.  A brief review of Piaget’s stages of development will help to meet the child at his developmental stage for best effect (Piaget 1928, Sheppard 1977) during acute painful presentations and minor procedures. Sensorimotor stage (from birth to age 2): Children use the five senses and movement to explore the world.  They are egocentric: they cannot see the world from another’s viewpoint.   At 6 to 9 months, object permanence is established: understanding that objects (or people) exist even without seeing them. Preoperational stage (from ages 2 to 7):  Children learn to use language.  Magical thinking predominates. They do not understand rational or logical thinking. Concrete operational stage (from age 7 to early adolescence): Children can use logic, but in a very straightforward, concrete manner (they do well with simple examples).  By this stage, they move from egocentrism to understanding another point of view.  N.B. Some children (and adults) never completely clear this stage. Formal operational stage (early adolescence to adult): children are capable of abstract thinking, rationalizing, and logical thinking. It is important to assess the child’s general level of development when preparing and guiding him through the minor procedure or distracting him until his pain is controlled.  It is not uncommon for acutely ill or injured to regress temporarily in their behavior (not their development) as a coping mechanism. Neonate and Infant (0-12 months) Involve the parent, and have the parent visible to the child at all times if possible.  Make advances slowly, in a non-threatening manner; limit the number of staff in the room.  Use soothing sensory measures: speak softly, offer a pacifier, and stroke the skin softly.  Swaddle the infant and encourage the parent to comfort him during and after the procedure.  Engage their developing sensorimotor skills to distract them. Toddler to Preschooler (1-5 years) Use the same techniques as for the infant, and add descriptions of what he will see, hear, and feel; you can use a doll or toy to demonstrate the procedure.  Use simple, direct language, and give calm, firm directions, one at a time.  Explain what you are doing just before doing it (do not allow too much time for fear or anxiety to take root).  Offer choices when appropriate; ignore temper tantrums.  Distraction techniques include storytelling, bright and flashy toys, blowing bubbles, pinwheels, or having another staff member play peek-a-boo across the room.  The ubiquitous smart phone with videos or games can be mesmerizing at this age. School age (6-12 years) Explain procedures using simple language and (briefly) the reason (understanding of bodily functions is vague in this age group).  Allow the child to ask questions, and involve him when possible or appropriate.  Distraction techniques may include electronic games, videos, guided imagery, and participation in the minor procedure as appropriate. Adolescent (13 and up) Use the same techniques for the school age child, but can add detail.  Encourage questioning.  Impose as few restrictions as possible – be flexible.  Expect more regression to childish coping mechanisms in this age group.  Distraction techniques include electronic games, video, guided imagery, muscle relaxation-meditation, and music (especially the adolescent’s own music, if available). APPLIED PHARMACOLOGY No amount of knowledge of the above physiology, pharmacology, or developmental theory will help your little patient in pain without a well constructed and enacted plan.  Aggressively search out and treat your pediatric patient’s presence and source of pain.  Frequent reassessments are important to ensure that breakthrough pain treatment is achieved, when re-administration is indicated, or when a change of plan is necessary.  This is the time to involve the parents or caregivers to let them know what the next steps are, and what to expect. Start with the least invasive modality and progress as needed.  After non-pharmacologic treatments such as splinting, ice, elevation, distraction, and guided imagery, have an escalation of care in mind (Figure 2). From a pharmacologic perspective, various options are available.  Your pain management plan will differ depending on whether a painful procedure is performed in the ED (Table 4).  Once pain is addressed, create a plan to keep it managed.  Consider the trajectory of illness and the expected time frame of the painful episode.  Include practicalities such as how well the pain may be controlled as an outpatient.  Poorly controlled pediatric pain is more often managed as an inpatient than the same condition in an adult.  Speak frankly with the parents about what drug is indicated for what type of pain and that treatment goals typically do not include absence of all pain, but function in face of the pain, in anticipation for clinical improvement. A special note on codeine: Tylenol with codeine (“T3”) has never been a very effective pain medication, as up to 10% of patients lack enzymatic activity to metabolize it into morphine, its active form (Crews 2014).  New evidence is emerging on the erratic and unpredictable individual metabolism of codeine.  Some children are ultra-rapid-metabolizers of codeine to morphine, causing a rapid “bolus” of the available drug, with respiratory depression and death in some cases (Ciszkowski 2009, Racoosin 2013).  Author’s advice: take codeine off your formulary. COMMON SCENARIOS Head and neck pain Most common non-traumatic head and neck complaints can be managed non-pharmacologically (e.g. headache: improved hydration, sleep, stress, nutrition) or with PO medications, such as NSAIDs.  The anti-inflammatory nature of ibuprofen (10 mg/kg PO q 4-6 h prn, up to adult dose) for example, will treat the cause as well as the symptoms of ear pain, sore throat, and muscular pain.  Ibuprofen may be more effective than acetaminophen (paracetamol) for odontogenic pain (Bailey 2013).  For most applications, acetaminophen may be as effective; however, the combination of both NSAIDs is not likely to be more effective than either agent individually (Merry 2013). True migraine headache may be treated with all of the above, and rescue therapy may include prochlorperamide (0.15 mg/kg IV, up to 10 mg ) (Brousseau 2004), often given with diphenhydramine (1 mg/kg PO or IV, up to 50 mg) and IV fluids.  Ketoralac (0.5 mg/kg IV, up to 10 mg) may be substituted for ibuprofen (Paniyot 2016).  Other specific therapies may be considered, although evidence for them varies. Chest pain After ruling out important pulmonary (e.g. the under-recognized spontaneous pneumothorax) and cardiac (e.g. pericarditis, myocarditis) etiologies, many chest complaints are amenable to NSAIDs.  There is often a large component of anxiety in the child and/or parents in chest pain; no amount of medication will assuage them without addressing their concerns as well. Abdominal pain Abdominal pain in children is challenging, as it is common, often benign, but may be disastrous if the etiology is missed.  For mild pain, consider acetaminophen as indicated (15 mg/kg/dose q 4-6 h prn, up to 650 mg).  The oral route is preferred, but intravenous acetaminophen is an option for patients unable to tolerate PO, or for those in whom the per rectum (PR) route is contraindicated (e.g. neutropenia) (Babl 2011, Dokko 2014).  For children with moderate to severe abdominal pain in whom a nil per os (NPO) status is ideal, consider rehydration/volume repletion, and small, frequent aliquots of a narcotic agent.  Surgical pain is not “erased” by opioids (Thomas 2003, Poonai 2014); treating pain improves specificity to certain surgical emergencies with retained diagnostic accuracy (Manterola 2007).  If there is inter-departmental concern about prolonged effects, sedation, limitation in the physical exam, or there is a need to “see if the pain will come back”, you may opt to use fentanyl initially for its shorter half-life.  More frequent re-assessments may help the surgical team in its deliberations.  Transition quickly to a longer-acting opioid as soon as possible. Long-bone injuries Fracture pain should be addressed immediately with splinting and analgesia.  Oral, intranasal, and intravenous routes are all acceptable, depending on the severity of the injury and symptoms. Intranasal (IN) medications offer the advantage of a fast onset for moderate-to-severe pain (Graudins 2015), either as monotherapy or as a bridge to parenteral treatment (Table 4).  The ideal volume of IN medication is 0.25 mL/naris, with a maximum of 1 mL/naris.  Common concentrations of fentanyl limit its mg/kg use to the school-aged child; intranasal ketamine may be used for pain (i.e. sub-dissociative dose) up to adult weight. Long-bone injuries are a good opportunity to employ a speedy modality that requires little technical skill in administration: nebulized fentanyl.  Clinically significant improvement in pain scales are achieved with 3 mcg/kg/dose of fentanyl administered via standard nebulizer in children 3 years of age or older (Miner 2007, Furyk 2009).  Nebulized fentanyl is a rapid, non-invasive alternative to the IN route for older children, adolescents, or adults, in whom the volume of IN medication would exceed the recommended per naris volume (Deaton 2015). Consider an aggressive, multi-modal approach to control symptom up front.  For example, for a simple forearm fracture, you may opt to give an oral opioid, perform a hematoma block, and offer inhaled nitrous oxide for reduction, rather than a formal intravenous procedural sedation (Luhmann 2006). Ultrasound-guided peripheral nerve blocks are a good pain control adjunct, after initial treatment, and in communication with referring consultants (Ganesh 2009, Suresh 2014). Skin and Soft tissue Skin and soft tissue injuries or abscesses often require solid non-pharmacopoeia in addition to local anesthetics.  For IV cannulation, consider EMLA if the patient is stable and a minor delay is acceptable. Topical ethyl chloride vapo-coolant offers transient pain relief due to rapid cooling and may be used just prior to an IV start (Farion 2008).  Try this: engage your young child’s imagination to distract him and say, “have you ever held a snow ball? You are in luck – it’s just like that – here, do you feel it?”. Vibratory adjuncts such as the “BUZZY” bee can be placed near the IV cannulation site to provide mechanical and cognitive distraction (Moadad 2016). Needleless lidocaine injectors may facilitate IV placement without obscuring the target vein (Spanos 2008, Lunoe 2015).  The medication is propelled into the dermis by a CO2 cartridge that makes a loud popping sound; try this to alleviate anxiety, just before using it: “your skin looks thirsty – it needs a drink – there you are!”. As with any minor procedure, when you tell the child what you are doing, be sure to do it right away.  Do not delay or build suspense. Lidocaine-epinephrine-tetracaine gel (LET) is used for open or mucosal wounds.  Apply as soon as possible in the visit.  The goal of LET is to pretreat the wound to allow for a painless administration of injectable anesthetic.  A common practice to apply LET two or three times at 15-minute intervals for deeper anesthesia, in an attempt to avoid injection altogether.  Researchers are currently working to offer an evidence base to this anecdotal practice. Pediatric burns should be assessed carefully and treated aggressively.  Submersion of the affected extremity in room-temperature water (if possible) or applying room-temperature saline-soaked gauze will both thwart ongoing thermal damage, soothe the wound, and provide foundational first-aid.  Minor burns can be treated topically and with oral medications.  Major burns require IN, IM, or IV analgesics with morphine.  Treatment may escalate to ketamine (Gandhi 2010), in analgesic or dissociative dosing, depending on the context.  Post-traumatic disorders are common in burns; effective pain management is ever-more important in these cases. SPECIFIC SCENARIOS The child with chronic medical problems Children with acute exacerbations of their chronic pain or episodic painful crises require special attention.  Some examples of children with recurring pain are those suffering from sickle cell disease, juvenile idiopathic arthritis, complex regional pain syndrome, and cancer.  Find out whether these symptoms and circumstances are typical for them, and what regimen has helped in the past.  Previous unpleasant experiences may prime these children with amplified anxiety and perception of pain (Cornelissen 2014).  Target the disease process and do your best to show the patient and his family you understand his condition and needs. An equally challenging scenario is the child with chronic pain.  Treat the entire patient with a multimodal approach.  Limit opioids as possible.  As an opioid-sparing strategy or as rescue therapy, consider sub-dissociative ketamine, especially for conditions such as sickle cell crisis, complex regional pain syndrome, autoimmune disorders, or chronic pain due to sub-acute trauma (Sheehy 2015). Intranasal ketamine may be used for sub-dissociative pain control at 0.5 – 1 mg/kg (Andolfatto 2013, Yeaman 2013).  Intravenous infusions of ketamine at 0.1 – 0.3 mg/kg/h may be initiated in the ED and continued 4 – 8 h/d, up to a maximum of 16 h total in 3 consecutive days (Sheehy 2015).  In vaso-occlusive episodes, dexmedetomidine has been shown to be an effective adjunct for severe pain poorly responsive to opioids and/or ketamine (Sheehy 2015b). The child with cognitive impairment Children with cognitive impairment such as those with various genetic or metabolic syndromes, or primary neurologic conditions such as some with cerebral palsy are a challenge to assess and treat properly.  These children not only cannot explain their symptoms, but they also have atypical expressions of pain.  Pain responses in severely intellectually disabled children include a full-blown smile (which may or may not accompany inappropriate laughter), stiffening, and non-cooperation (Hadden 2002).  Other observed behaviors include the freezing phenomenon, in which the child acutely feels the pain, and he abruptly pauses without moving his face for several seconds.  Look also for episodes of unexplained pallor, diaphoresis, breath-holding, and shrill vocalizations. The FLACC has been revised (r-FLACC) for children with cognitive impairment and appears to be reliable for acute care (Malviya 2006). The most distressing and perplexing presentation is the parent who brings his or her child with cognitive impairment for “fussiness”, “irritability”, or “I think he’s in pain”.  Often, this is after significant investigations have been performed, sometimes repeatedly.  Poorly controlled spasticity is an often under-appreciated cause of unexplained pain; treat not with opioids, but with GABA-receptor agonists, such as baclofen or benzodiazepines. Take special precautions in the administration of opioids or benzodiazepines in children with metabolic disorders (e.g. mitochondrial disease) or various syndromes (e.g. Trisomy 21).  They may have a disproportionate reaction to the medication.  Start with a low dose in these children and reassess frequently, titrating in small aliquots as needed. After careful, meticulous investigation in the ED to rule out occult infection, trauma, electrolyte imbalance, or surgical causes, the child with cognitive impairment who continues to be symptomatic despite ED treatment may be admitted for observation.  However, in some cases, the addition of gabapentin to the typical regimen has been shown to manage unexplained irritability in these children (Hauer 2007) by treating visceral hyperalgesia. Multi-trauma The child with multi-trauma is in need of meticulous critical care.  Frequent assessments of pain analgesic response (typically via the intravenous route) are necessary to gauge the child’s trajectory.  Unexplained tachycardia may be the early signs of shock.  Without controlling the child’s pain, it is difficult to distinguish the extreme tachycardia from pain or from blood loss.  If intubated, control the pain first with a fentanyl drip, then use a sedative in addition as needed to keep him comfortable. The child under palliative care Children undergoing palliative care require a multidisciplinary approach.  This includes engaging the patient’s car team as well as “treating” members of the patient’s family.  Examples include the natural course of devastating chromosomal, neurologic, and other congenital conditions; terminal cancer; and trauma, among others (Michelson 2007).  Family dynamics and family members’ needs are often overlooked; the family as a whole must be considered.  Focus on the productive and beneficial treatments that can be offered.  Treat pain promptly, but speak with the parents about end-of-life goals as early as possible, as any analgesic or sedative may have an untoward effect.  You do not want to be caught in the position of potentially precipitously providing cardiopulmonary resuscitation in a child undergoing palliative care, because of a lack of understanding of how increasingly large doses of pain medications can affect breathing and circulation (AAP 2000). Children with ongoing opioid requirements may present not so much with an exacerbation of their chronic pain, but a complication of its treatment.  Identify, assess and aggressively treat constipation, nausea and vomiting, pruritus, and urinary retention (Friedrichsdorf 2007); treating side-effects of pain management may be just as important for quality of life as treating the pain itself. PEARLS AND PITFALLS IN PEDIATRIC PAIN Allow the child to speak for himself whenever possible.  After acknowledging the parent’s input, perhaps try “I want to make sure I understand how the pain is for you.  Tell me more.” Engage parents and communicate the plan to them.  Elicit their expectations, and give them of preview of what to expect in the ED. Opioids are meant for pain caused by acute tissue injury, for the briefest period of time feasible.  Older school-aged children and adolescents are increasingly at risk for opioid dependence and addiction. Premature infants present a challenge in pain control.  Their pain is under-recognized, as they often display atypical responses to painful stimuli.  Treatment is equally difficult, as they are particularly sensitive to analgesia-sedation.  This is important, as this group is even more likely to undergo painful procedures due to their higher-risk status. Give detailed advice on how to manage pain at home.  Set expectations.  Let them know you understand and will help them through your good advice that will carry them through this difficult time.  Patients and families often just need a plan.  Map it out clearly. SUMMARY In pediatric acute pain, know the child; know the family; and know the physiology. Use your observational skills enhanced with collateral information to assess and reassess for pain in children. Treat pediatric pain well and often. Failure to address the child’s pain has long-lasting consequences. Non-pharmacologic treatments for all, pharmacologic treatments for many. A multi-modal approach is the most effective. Neonates, infants and toddlers, and school-aged children and adolescents exhibit specific physiology in expression of pain and in response to treatment. Tailor your regimen to your young patient’s physiologic pitfalls and needs. References American Academy of Pediatrics. Committee on Bioethics and Committee on Hospital Care. Palliative care for children. Pediatrics. 2000 Aug;106(2 Pt 1):351-7. Andolfatto G, Willman E, Joo D, Miller P, Wong WB, Koehn M, Dobson R, Angus E, Moadebi S. Intranasal ketamine for analgesia in the emergency department: a prospective observational series. Acad Emerg Med. 2013 Oct;20(10):1050-4. Babl FE, Theophilos T, Palmer GM. Is there a role for intravenous acetaminophen in pediatric emergency departments? Pediatr Emerg Care. 2011 Jun;27(6):496-9. Bailey E, Worthington HV, van Wijk A, Yates JM, Coulthard P, Afzal Z. Ibuprofen and/or paracetamol (acetaminophen) for pain relief after surgical removal of lower wisdom teeth.Cochrane Database Syst Rev. 2013 Dec 12;(12):CD004624. Bearden DJ, Feinstein A, Cohen LL. The influence of parent preprocedural anxiety on child procedural pain: mediation by child procedural anxiety. J Pediatr Psychol. 2012 Jul;37(6):680-6. Berde CB, Sethna NF. Analgesics for the treatment of pain in children. N Engl J Med. 2002 Oct 3;347(14):1094-103. Brousseau DC, Duffy SJ, Anderson AC, Linakis JG. Treatment of pediatric migraine headaches: a randomized, double-blind trial of prochlorperazine versus ketorolac. Ann Emerg Med. 2004 Feb;43(2):256-62. Ciszkowski C, Madadi P, Phillips MS, Lauwers AE, Koren G. Codeine, ultrarapid-metabolism genotype, and postoperative death. N Engl J Med. 2009 Aug 20;361(8):827-8. Cornelissen L, Donado C, Kim J, Chiel L, Zurakowski D, Logan DE, Meier P, Sethna NF, Blankenburg M, Zernikow B, Sundel RP, Berde CB. Pain hypersensitivity in juvenile idiopathic arthritis: a quantitative sensory testing study. Pediatr Rheumatol Online J. 2014 Sep 6;12:39. Crews KR, Gaedigk A, Dunnenberger HM, Leeder JS, Klein TE, Caudle KE, Haidar CE, Shen DD, Callaghan JT, Sadhasivam S, Prows CA, Kharasch ED, Skaar TC; Clinical Pharmacogenetics Implementation Consortium. Clinical Pharmacogenetics Implementation Consortium guidelines for cytochrome P450 2D6 genotype and codeine therapy: 2014 update. Clin Pharmacol Ther. 2014 Apr;95(4):376-82. Deaton T, Auten JD, Darracq MA. Nebulized fentanyl vs intravenous morphine for ED patients with acute abdominal pain: a randomized double-blinded, placebo-controlled clinical trial. Am J Emerg Med. 2015 Jun;33(6):791-5. Dokko D. Best practice for fever management with intravenous acetaminophen in pediatric oncology. J Pediatr Oncol Nurs. 2015 Mar-Apr;32(2):120-5. Farion KJ, Splinter KL, Newhook K, Gaboury I, Splinter WM. The effect of vapocoolant spray on pain due to intravenous cannulation in children: a randomized controlled trial. CMAJ. 2008 Jul 1;179(1):31-6. Finley GA, Kristjánsdóttir O, Forgeron PA. Cultural influences on the assessment of children's pain. Pain Res Manag. 2009 Jan-Feb;14(1):33-7. Friedrichsdorf SJ, Kang TI. The management of pain in children with life-limiting illnesses. Pediatr Clin North Am. 2007 Oct;54(5):645-72. Furyk JS, Grabowski WJ, Black LH. Nebulized fentanyl versus intravenous morphine in children with suspected limb fractures in the emergency department: a randomized controlled trial. Emerg Med Australas. 2009 Jun;21(3):203-9. Gandhi M, Thomson C, Lord D, Enoch S.  Management of Pain in Children with Burns. Int J Pediatr. 2010; 2010: 825657. Ganesh A, Gurnaney HG. Ultrasound guidance for pediatric peripheral nerve blockade. Anesthesiol Clin. 2009 Jun;27(2):197-212. Graudins A, Meek R, Egerton-Warburton D, Oakley E, Seith R. The PICHFORK (Pain in Children Fentanyl or Ketamine) trial: a randomized controlled trial comparing intranasal ketamine and fentanyl for the relief of moderate to severe pain in children with limb injuries. Ann Emerg Med. 2015 Mar;65(3):248-254.e1. Hadden KL, von Baeyer CL. Pain in children with cerebral palsy: common triggers and expressive behaviors. Pain. 2002 Sep;99(1-2):281-8. Harrison D, Bueno M, Yamada J, Adams-Webber T, Stevens B. Analgesic effects of sweet-tasting solutions for infants: current state of equipoise. Pediatrics. 2010 Nov;126(5):894-902. Hauer JM, Wical BS, Charnas L. Gabapentin successfully manages chronic unexplained irritability in children with severe neurologic impairment. Pediatrics. 2007 Feb;119(2):e519-22. Horeczko T, Mahmoud MA. The sedation mindset: philosophy, science, and practice. Curr Opin Anaesthesiol. 2016 Feb;29 Suppl 1:S48-55. Howard RF. Current status of pain management in children. JAMA. 2003 Nov 12;290(18):2464-9. Keck JF, Gerkensmeyer JE, Joyce BA, Schade JG. Reliability and validity of the Faces and Word Descriptor Scales to measure procedural pain. J Pediatr Nurs. 1996 Dec;11(6):368-74. Krechel SW, Bildner J. CRIES: a new neonatal postoperative pain measurement score. Initial testing of validity and reliability. Paediatr Anaesth. 1995;5(1):53. Lawrence J, Alcock D, McGrath P, Kay J, MacMurray SB, Dulberg C. The development of a tool to assess neonatal pain. Neonatal Netw. 1993;12(6):59–66. Liebelt EL. Assessing children's pain in the emergency department. Clin Pediatr Emerg Med. 2000; 1(4):260-269. Luhmann JD, Schootman M, Luhmann SJ, Kennedy RM. A randomized comparison of nitrous oxide plus hematoma block versus ketamine plus midazolam for emergency department forearm fracture reduction in children. Pediatrics. 2006 Oct;118(4):e1078-86. Lunoe MM, Drendel AL, Levas MN, Weisman SJ, Dasgupta M, Hoffmann RG, Brousseau DC. A Randomized Clinical Trial of Jet-Injected Lidocaine to Reduce Venipuncture Pain for Young Children. Ann Emerg Med. 2015 Nov;66(5):466-74. Malviya S, Voepel-Lewis T, Burke C, Merkel S, Tait AR. The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment. Paediatr Anaesth. 2006 Mar;16(3):258-65. Manterola C, Astudillo P, Losada H, Pineda V, Sanhueza A, Vial M. Analgesia in patients with acute abdominal pain. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD005660. Maxwell LG, Malavolta CP, Fraga MV. Assessment of pain in the neonate. Clin Perinatol. 2013 Sep;40(3):457-69. Merry AF, Edwards KE, Ahmad Z, Barber C, Mahadevan M, Frampton C. Randomized comparison between the combination of acetaminophen and ibuprofen and each constituent alone for analgesia following tonsillectomy in children. Can J Anaesth. 2013 Dec;60(12):1180-9. Michelson KN, Steinhorn DM. Pediatric End-of-Life Issues and Palliative Care. Clin Pediatr Emerg Med. 2007 Sep; 8(3): 212–219. Miner JR, Kletti C, Herold M, Hubbard D, Biros MH. Randomized clinical trial of nebulized fentanyl citrate versus i.v. fentanyl citrate in children presenting to the emergency department with acute pain. Acad Emerg Med. 2007 Oct;14(10):895-8. Moadad N, Kozman K1, Shahine R, Ohanian S, Badr LK. Distraction Using the BUZZY for Children During an IV Insertion. J Pediatr Nurs. 2016 Jan-Feb;31(1):64-72. Patniyot IR, Gelfand AA. Acute Treatment Therapies for Pediatric Migraine: A Qualitative Systematic Review. Headache. 2016 Jan;56(1):49-70. Pasero C, McCaffery M. Pain Assessment and Pharmacologic Management. St. Louis, Mo: Mosby; 2011. Piaget J. Judgment and reasoning in the child. Harcourt & Brace. Oxford, England. 1928. Poonai N, Paskar D, Konrad SL, Rieder M, Joubert G, Lim R, Golozar A, Uledi S, Worster A, Ali S. Opioid analgesia for acute abdominal pain in children: A systematic review and meta-analysis. Acad Emerg Med. 2014 Nov;21(11):1183-92. Racoosin JA, Roberson DW, Pacanowski MA, Nielsen DR. New evidence about an old drug--risk with codeine after adenotonsillectomy. N Engl J Med. 2013 Jun 6;368(23):2155-7. Sheehy KA, Muller EA, Lippold C, Nouraie M, Finkel JC, Quezado ZM. Subanesthetic ketamine infusions for the treatment of children and adolescents with chronic pain: a longitudinal study. BMC Pediatr. 2015 Dec 1;15:198. Sheehy KA, Finkel JC, Darbari DS, Guerrera MF, Quezado ZM. Dexmedetomidine as an Adjuvant to Analgesic Strategy During Vaso-Occlusive Episodes in Adolescents with Sickle-Cell Disease. Pain Pract. 2015 Nov;15(8):E90-7. Sheppard JL. The application of Piaget's theory to physiotherapy. Aust J Physiother. 1977 Dec;23(4):133-40. Spanos S, Booth R, Koenig H, Sikes K, Gracely E, Kim IK. Jet Injection of 1% buffered lidocaine versus topical ELA-Max for anesthesia before peripheral intravenous catheterization in children: a randomized controlled trial. Pediatr Emerg Care. 2008 Aug;24(8):511-5. Srouji R, Ratnapalan S, Schneeweiss S. Pain in children: assessment and nonpharmacological management. Int J Pediatr. 2010;2010. Stevens B, Yamada J, Lee GY, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database of Systematic Reviews 2013, Issue 1. Art. No.: CD001069. Suresh S, Sawardekar A, Shah R. Ultrasound for regional anesthesia in children. Anesthesiol Clin. 2014 Mar;32(1):263-79. Taddio A, Shah V, Gilbert-MacLeod C, Katz J. Conditioning and hyperalgesia in newborns exposed to repeated heel lances. JAMA. 2002;288(7):857. Thomas SH, Silen W. Effect on diagnostic efficiency of analgesia for undifferentiated abdominal pain. Br J Surg. 2003 Jan;90(1):5-9. Tomlinson D, von Baeyer CL, Stinson JN, Sung L. A systematic review of faces scales for the self-report of pain intensity in children. Pediatrics. 2010 Nov;126(5):e1168-98. Tsze DS, von Baeyer CL, Bulloch B, Dayan PS. Validation of Self-Report Pain Scales in Children. Pediatrics. 2013 Oct; 132(4): e971–e979. Voepel-Lewis T, Merkel S, Tait AR, Trzcinka A, Malviya S. The reliability and validity of the Face, Legs, Activity, Cry, Consolability observational tool as a measure of pain in children with cognitive impairment. Anesth Analg. 2002 Nov;95(5):1224-9. Yeaman F, Oakley E, Meek R, Graudins A. Sub-dissociative dose intranasal ketamine for limb injury pain in children in the emergency department: a pilot study. Emerg Med Australas. 2013 Apr;25(2):161-7   This post and podcast are dedicated to Sergey M. Motov, MD, FAAEM, for his integrity, hard-won expertise, humility, and innovation.  Thank you for making us better doctors, Sergey, and for getting us ever closer to a pain-free ED. Pediatric Pain Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP

"By the pricking of my thumbs, Something wheezing this way comes." -- Witches in Macbeth, with apologies to William Shakespeare   "Bronchiolitis is like a pneumonia you can’t treat. We support, while the patient heals." -- Coach, still apologetic to the Bard     The Who The U.S. definition is for children less than two years of age, while the European committee includes infants less than one year of age. This is important: toddlerhood brings with it other conditions that mimic bronchiolitis – the first-time wheeze in a toddler may be his reactive airway response to a viral illness and not necessarily bronchiolitis. The What The classic clinical presentation of bronchiolitis starts just like any other upper respiratory tract infection: with nasal discharge and cough, for the first 1-2 days. Only about 1/3 of infants will have a low-grade fever, usually less than 39°C. We may see the child in the ED at this point and not appreciate any respiratory distress – this is why precautionary advice is so important in general. Then, lower respiratory symptoms come: increased work of breathing, persistent cough, tachypnea, retractions, belly breathing, grunting, and nasal flaring. Once lower respiratory symptoms are present, like increased work of breathing, they typically peak at day 3. This may help to make decisions or counsel parents depending on when the child presents and how symptomatic he is. You’ll hear fine crackles and wheeze. A typical finding in bronchiolitis is a minute-to-minute variation in clinical findings – one moment the child could look like he’s drowning in his secretions, and the next minute almost recovered. This has to do with the dynamic nature of the secretion, plugging, obstruction, coughing, dislodgement, and re-plugging. The Why Respiratory syncytial virus is the culprit in up to 90% of cases of bronchiolitis. The reason RSV is so nasty is the immune response to the virus: it binds to epithelial cells, replicates, and the submucosa becomes edematous and hypersecretes mucus. RSV causes the host epithelia and lymphocytes to go into a frenzy – viral fusion proteins turn the membranes into a sticky goop – cells fuse into other cells, and you have a pile-on of multinucleated dysfunction. This mucosal chaos causes epithelial necrosis, destruction of cilia, mucus plugs, bronchiolar obstruction, air trapping, and lobar collapse. High-Risk Groups Watch out especially for young infants, so those less than 3 months of age. Apnea may be the presenting symptom of RSV. Premature infants, especially those less than 32 weeks’ gestation are at high risk for deterioration.  The critical time is 48 weeks post-conceptional age. Other populations at high-risk for deterioration: congenital heart disease, pulmonary disease, neuromuscular disorders, metabolic disorders. Guiding Principles In the full term child, greater than one month, and otherwise healthy (no cardiac, pulmonary, neuromuscular, or metabolic disease), we can look to three simple criteria for home discharge. If the otherwise healthy child one month and older is: Euvolemic Not hypoxic Well appearing He can likely go home. The How Below is a list of modalities, treatments, and the evidence and/or recommendations for or against: Chest Radiograph Usually not necessary, unless the diagnosis is uncertain, or if the child is critically ill. Factors that are predictive of a definite infiltrate are: significant hypoxia (< 92%), grunting, focal crackles, or high fever (> 39°C). Ultrasound Not ready for prime time.  Two small studies, one by Caiulo et al in the European J or Pediatrics and one by Basile et al. in the BMC Pediatrics that show some preliminary data, but not enough to change practice yet. Viral Testing Qualitative PCR gives you a yes or no question – one that you’ve already answered. It is not recommended for routine use. PCR may be positive post-infection for several weeks later (details in audio). Quantitative PCR measures viral load; an increased quantitative viral load is associated with increased length of stay, use of respiratory support, need for intensive care, and recurrent wheezing. However, also not recommended for routine use. There is one instance in which viral testing in bronchiolitis can be helpful – in babies less than a month of life, the presence of RSV virus is associated with apnea. Blood or Urine Testing Routine testing of blood or urine is not recommended for children with bronchiolitis.  Levine et al in Pediatrics found an extremely low risk of serious bacterial illness in young febrile infants with RSV. The main thing is not to give in to anchoring bias here. If an infant of 3 months of age or older has a clear source for his low-grade fever – and that is his bronchiolitis – then you have a source, and very rarely do you need to go looking any further. He’s showing you the viral waterfall from his nose, and his increased work of breathing. It’s not going to be in his urine. Bronchodilators! Should we use bronchodilators in bronchiolitis?  It seems lately that this is a loaded question – with strong feelings on either side amongst colleagues. The short answer is that the American Academy of Pediatrics, the UK’s National Institute for Health and Care Excellence, as well as the Canadian Pediatric Society currently recommend against them. However, in continental Europe and Australia, the language is softened to “not routinely recommended”. Pros and Cons in Audio; the 2006 AAP Guidelines and the 2014 AAP Guidelines use same data to come to divergent recommendations. Steroids There is no role for steroids in the treatment of bronchiolitis, even in those with a family or personal history of atopy. Nebulized Hypertonic Saline May show some benefit in admitted patients, after repeated treatments; no data to support its use in ED patients (no immediate effect). Nebulized Epinephrine One randomized controlled double blinded study in eight centers in Norway published in the NEJM showed no benefit to nebulized epinephrine over nebulized saline. Again, probably asking too much of one single intervention. The Cochrane review found 19 studies that included a total of 2256 children with acute bronchiolitis treated with nebulized epinephrine. There were no differences in length of hospital stay between the placebo and treatment groups, and so they concluded that for inpatients, nebulized epinephrine is not worth the hassle. However – and this may just be an artifact of meta-analysis – there may be some benefit to outpatients. One study of combined high-dose steroid and epinephrine therapy was not statistically significant when other factors were controlled, but Cochrane concluded that nebulized epinephrine itself may be helpful for outpatients. It won’t affect the overall disease time course, but it may make them feel better enough to go home from the ED and continue observation there. High-Flow Nasal Cannula Oxygen High-flow oxygen via nasal cannula requires specialized equipment and delivers humidified oxygen at 1-2 L/g/min.  In addition to oxygenation, high flow nasal cannula also likely offers some low-grade positive end-expiratory pressure, which may help with alveolar recruitment. The evidence for its use is based on observational studies, which have found improved respiratory parameters and reduced rates of intubation.  Nasal CPAP also has some promising properties in the right clinical setting. Antibiotics Not recommended. When bronchiolitis is from a clear viral source, the risk of accompanying bacteremia is less than 1%. A meta-analysis of randomized clinical trials found that antibiotics in bronchiolitis did not improve duration of symptoms, length of hospital stay, need for oxygen therapy, or hospital admission. Summary: The Good, the Bad, and the Ugly The Good Nasal suction and hydration are your best allies. You may elect to give a bronchodilator as a trial once and reexamine, if you’re a bronchodilating believer. The Bad Steroids, antibiotics, and a blind obeying of the guidelines. Weigh the risks and benefits of every intervention, including hospitalization – it’s not always a benign thing. The Ugly Take a moment to assess the child and make a clinical diagnosis of bronchiolitis, after you’ve excluded cardiac disease, anatomic anomalies, and foreign body aspiration. Wheezing without upper respiratory symptoms is not viral, and it is not bronchiolitis. When all else fails, remember: in the otherwise healthy, term infant greater than a month of age, if he is well appearing, euvolemic, and not hypoxic, he will often do well with good precautionary advice and supportive care at home. Every thing else: be skeptical, be thorough, and above all, be careful. References Alansari K, Toaimah FH, Khalafalla H, El Tatawy LA, Davidson BL, Ahmed W. Caffeine for the Treatment of Apnea in Bronchiolitis: A Randomized Trial. J Pediatr. 2016 May 14. pii: S0022-3476(16)30170-6. [Epub ahead of print] American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006 Oct;118(4):1774-93. Beggs S, Wong ZH, Kaul S, Ogden KJ, Walters JA. High-flow nasal cannula therapy for infants with bronchiolitis. Cochrane Database Syst Rev. 2014 Jan 20;(1):CD009609. Bergroth E, Aakula M, Korppi M, Remes S, Kivistö JE, Piedra PA, Camargo CA Jr, Jartti T. Post-bronchiolitis Use of Asthma Medication: A Prospective 1-year Follow-up Study. Pediatr Infect Dis J. 2016 Apr;35(4):363-8. Cunningham S, Rodriguez A, Adams T, Boyd KA, Butcher I, Enderby B, MacLean M, McCormick J, Paton JY, Wee F, Thomas H, Riding K, Turner SW, Williams C, McIntosh E, Lewis SC; Bronchiolitis of Infancy Discharge Study (BIDS) group. Oxygen saturation targets in infants with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial. Lancet. 2015 Sep 12;386(9998):1041-8. Flett KB, Breslin K, Braun PA, Hambidge SJ. Outpatient course and complications associated with home oxygen therapy for mild bronchiolitis. Pediatrics. 2014 May;133(5):769-75. Florin TA, Plint AC, Zorc JJ. Viral bronchiolitis. Lancet. 2016 Aug 20. [Epub ahead of print] Halstead S, Roosevelt G, Deakyne S, Bajaj L. Discharged on supplemental oxygen from an emergency department in patients with bronchiolitis. Pediatrics. 2012 Mar;129(3):e605-10. Johnson LW, Robles J, Hudgins A, Osburn S, Martin D, Thompson A. Management of bronchiolitis in the emergency department: impact of evidence-based guidelines? Pediatrics. 2013 Mar;131 Suppl 1:S103-9. Lashkeri T, Howell JM, Place R. Capnometry as a predictor of admission in bronchiolitis. Pediatr Emerg Care. 2012 Sep;28(9):895-7. Lehners N, Tabatabai J, Prifert C, Wedde M, Puthenparambil J, Weissbrich B, Biere B, Schweiger B, Egerer G, Schnitzler P. Long-Term Shedding of Influenza Virus, Parainfluenza Virus, Respiratory Syncytial Virus and Nosocomial Epidemiology in Patients with Hematological Disorders. PLoS One. 2016 Feb 11;11(2):e0148258. Liet JM, Ducruet T, Gupta V, Cambonie G. Heliox inhalation therapy for bronchiolitis in infants. Cochrane Database Syst Rev. 2015 Sep 18;(9):CD006915. Mammas IN, Spandidos DA. Paediatric Virology in the Hippocratic Corpus. Exp Ther Med. 2016 Aug;12(2):541-549. Mansbach JM, Clark S, Teach SJ, Gern JE, Piedra PA, Sullivan AF, Espinola JA, Camargo CA Jr. Children Hospitalized with Rhinovirus Bronchiolitis Have Asthma-Like Characteristics. J Pediatr. 2016 May;172:202-204.e1. Meissner HC. Viral Bronchiolitis in Children. N Engl J Med. 2016 Jan 7;374(1):62-72. Munywoki PK, Koech DC, Agoti CN, Kibirige N, Kipkoech J, Cane PA, Medley GF, Nokes DJ. Influence of age, severity of infection, and co-infection on the duration of respiratory syncytial virus (RSV) shedding. Epidemiol Infect. 2015 Mar;143(4):804-12. Oakley E, Borland M, Neutze J, Acworth J, Krieser D, Dalziel S, Davidson A, Donath S, Jachno K, South M, Theophilos T, Babl FE; Paediatric Research in Emergency Departments International Collaborative (PREDICT). Nasogastric hydration versus intravenous hydration for infants with bronchiolitis: a randomised trial. Lancet Respir Med. 2013 Apr;1(2):113-20. Epub 2012 Dec 21. Oakley E et al. Nasogastric Hydration in Infants with Bronchiolitis Less Than 2 Months of Age. J Pediatr. 2016. [Article in Press] Principi T, Coates AL, Parkin PC, Stephens D, DaSilva Z, Schuh S. Effect of Oxygen Desaturations on Subsequent Medical Visits in Infants Discharged From the Emergency Department With Bronchiolitis. JAMA Pediatr. 2016 Jun 1;170(6):602-8. Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, Johnson DW, Light MJ, Maraqa NF, Mendonca EA, Phelan KJ, Zorc JJ, Stanko-Lopp D, Brown MA, Nathanson I, Rosenblum E, Sayles S 3rd, Hernandez-Cancio S; American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014 Nov;134(5):e1474-502. Roqué i Figuls M, Giné-Garriga M, Granados Rugeles C, Perrotta C, Vilaró J. Chest physiotherapy for acute bronchiolitis in paediatric patients between 0 and 24 months old. Cochrane Database Syst Rev. 2016 Feb 1;2:CD004873. Skjerven HO et al. Racemic adrenaline and inhalation strategies in acute bronchiolitis. N Engl J Med. 2013 Jun 13;368(24):2286-93. This post and podcast are dedicated to Linda Girgis MD, FAAFP, for her authenticity, innovation, and clear and honest voice on the the frontlines.  Thank you, Dr Linda. Bronchiolitis Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP

Seemingly vague, but potentially dangerous... common, but possibly with consequences... ...or maybe just plain frustrating. Let's talk risk stratification, diagnosis, and management. Primary or Secondary? We can make headache as easy or as complicated as we like, but let's break it down to what we need to know now, and what the parents need to know when they go home. Primary headaches: headaches with no sinister secondary cause – like tension or migraine – are of course diagnoses of exclusion (cluster headache is exceedingly rare in children). Secondary headaches: headaches due to some underlying cause -- are what we need to focus on first. The list of etiologies is vast; here is just a sampling: How do I sort this out? Ask yourself three main questions: Is it a tumor? Is it an infection? Is it a bleed? Is it a tumor? Some historical features are high-yield in screening for signs or symptoms consistent with a space occupying lesion. Progression and worsening of symptoms over time Associated vomiting Pain only in the occiput Headache that is worse with Valsalva – ask if coughing, urinating, or defecating affects the headache Does this headache wake the child from sleep? Is it worse in the morning just after getting up? Conversely, the absence of some historical features may increase suspicion of a space-occupying lesion No family history of migraine No associated aura with the headache. Who needs neuroimaging? The short answer is, if the child has an abnormal exam finding, then obtain a non-contrast head CT in the ED.  If you’re worried enough to get imaging, then you should not feel great about sending him to an expedition to MRI. The reassuring point is that for a child with a normal neuro exam, we have time to figure this out. For the recurrent headache, outpatient MRI really is the way to go if at all possible – not only do we forgo unnecessary radiation, but MRI is more likely to reveal the cause – or rule out the concern. Medina et al. in Pediatrics reported on children with headache suspected of having a brain tumor. They stratified patients into low, intermediate, and high risk, based on clinical predictors from the history and physical. All had imaging. They then calculated probability of tumor in each group. The low risk group had a 0.01% probability of tumor. The intermediate group 0.4%, and the high-risk group had only a 4% probability of tumor. The take-home message is that in the stable patient with a normal neurologic exam and no red flags, time is on our side. The American Academy of Neurology's most recent guidelines, published first in 1994 and revised in 2004. 1. Neuroimaging on a routine basis is not indicated with recurrent headaches and a normal neurologic exam 2. Neuroimaging should be considered in children with an abnormal exam. 3. Neuroimaging should be considered in children with recent onset of severe headache, change in the type of headache, or associated features that suggest neurologic dysfunction Is it an infection? This is nothing new: if you think you need to perform a lumbar puncture, then you’re right. Go after the diagnosis when it meets your threshold for testing. The difficulty is in the child who just has a headache, plus or minus symptoms that may be viral syndrome. Dr Curtis et al. in Pediatrics did a systematic review of Clinical Features Suggestive of Meningitis in Children.  In the history, only obvious features were helpful in this study: bulging fontanel in the infant or neck stiffness in the older child.  Both increased the likelihood of meningitis by 8-fold. In the physical examination, the only reliable predictors in this study were poor general appearance or a change in behavior. You will catch those cases, because you would have tuned into meningitis early on -- especially in the unvaccinated. What about all-comers with fever and headache? The presence of a high fever (so greater than 40 °C) only conferred a positive likelihood ratio of 2.9, only marginally predictive. Reassuring is that for temperatures less than 40 °C, the LR was 1 for meningitis. In other words, a fever less than 40 °C was just as likely to be present with or without meningitis. Is it a bleed? Does this child have some underlying disorder? For example, sickle cell disease, hypertension, rheumatologic disease, or some other endocrine or metabolic disease, such as a mitochondrial disorder? In chronically ill children, consider cerebral sinus venous thrombosis, vasculitis, ischemia, or hemorrhage. Arteriovenous malformation (AVM) is the hemorrhage we fear the most. We really don’t know enough about arteriovenous malformations in the brain to say what is the typical presentation. They may be completely asymptomatic, until they rupture. Even the headache presentation is variable. Think, headache PLUS. New headache plus…vomiting. Headache plus…it’s unilateral and new for the patient. Headache plus…a new seizure. Headache plus…focal neuro deficits, that may be transient, due to a vascular steal phenomenon. Two illustrative cases of arteriovenous malformation: 1. An eleven-year-old girl presents to the ED with new headache, nausea, and vomting in the morning, then had a generalized seizure later that day, and presents with a low GCS. She was intubated, CT confirmed the AVM. She had a right frontal intraparenchymal bleed with midline shift. She underwent clot evacuation and extirpation of the intertwined arteries and veins. 2. A nine-year old girl presented to the ED with headache for two days, constant, then one day of nausea and vomiting. On presentation, she was altered, and had slow-reacting pupils. She also underwent evacuation, and only on histopathology did they find a single, arterialized vein. Primary Headache: Presumptive Impression Tension headaches are the most common in children and adults. As in adults, the tension headache is band-like, pressure, tighetening, and often associated with muscle aches in the neck and shoulders. Find out how often they occur, and whether there is any pattern of worsening symptoms, or if the symptoms seem to be related to sleep hygiene, video games, too much digital screen time. Also, screen for lack of exercise, poor diet, stress, and all of the other good questions you usually ask. Treat the cause or counsel about lifestyle modification, and offer PO hydration and an NSAID, like ibuprofen or acetaminophen (paracetamol). Non-pharmacologic techniques like heat packs, rest, stress relief, and a little TLC always help. Be careful not to encourage overreacting to the headache – sometimes we see a pattern of headache, attention, and more headache that can take root. Also look for overuse of medications, which may be the culprit in up to 50% of chronic headaches. Taking NSAIDs 3 or more times per week is associated with medication-induced headache, or cephalalgia medicamentosa. We often fail to identify migraine headaches in children in the ED, likely for two reasons: prevalence of migraine increases with age, and children don’t present exactly like adults. Stewart et al. in Neurology, report a prevalence of migraine in children that increases with age: 3 to 7 years of age was 2%; 7 to 11 years of age, 7%; and 11 to 20 years of age, 20% Pearl: migraines are most commonly bilateral and temporal in children.  They resemble "adult" tension headaches, but are much more severe. We may not be able to sort this out in the ED.  The point here is that migraines in children are more common that we may expect, and they can interfere with school performance, with social development, or even with family dynamics and overall stress burden. Primary Headache Diagnosis: Not (Usually) "Our Thing" You noticed that we treated before we knew exactly the etiology; such is Emergency Medicine. We may not be able to make a specific, definitive primary headache diagnosis in the ED, but we should be aware of the criteria to help counsel patients and families. Tension headache is the most common, but it requires multiple, similar episodes: Migraine headache (without aura) requires less episodes, but more specific features: An aura is a fast-pass to diagnosis of migraine:   Primary Headache Management So how do we treat primary headaches? If you feel this is a mild tension headache, fluids by mouth and a simple NSAID are probably all that is needed, in addition to a heaping dose of reassurance.  Ibuprofen (10 mg/kg/dose q 6h, up to 600 mg) for a short course has the most evidence basis.  Acetaminophen (paracetamol) (15 mg/kg/dose q6 h) for a short course may also be given. Abortive treatments with the triptans may have been tried at home, but if they are coming to see us, we are past the point where triptans will be helpful. For the primary headache that is resistant to NSAIDs, IV therapy may be considered. If you’re going for IV, a nice evidence-based migraine cocktail is the following: 1. A bolus of 20 ml/kg of normal saline, up to a liter 2. Ketorolac (0.5 mg/kg; max, 30 mg) 3. Diphenhydramine (2 mg/kg; max, 50 mg) 4. Prochlorperazine (0.1 mg/kg; max, 10 mg) Dr Kaar et al. in Pediatric Emergency Care evaluated the safety and efficacy of their institution’s standardized pediatric migraine practice guideline in the emergency department, which used ths cocktail, based on the best evidence available. In their retrospective chart review, they found the average visual pain scale drop from 7.8 to 2.1 There were no adverse events reported. So, really you can treat children with migraines very similarly to adults. Other treatments on the horizon (still under investigation) in children include IV adjuncts such as magnesium, valproic acid, and dexamethasone. Aftercare and Recurrence Prevention For everyone who is going home, take just a moment to talk about the importance of sleeping well, eating well, getting exercise, limiting digital screen time, and trying to improve ways of dealing with stress. When all else fails, and the parent has “heard it all”: get them started on a headache diary. Take a piece of paper, fold it in half, and start a template for them to work on in a spiral notebook.  Start a sample entry for them, with the date and time the headache started, what it felt like, what was happening just before, what made the headache better, any dose of medications given, how long it lasted, and what the patient did after. There are even free apps that will track the headache pattern. This is the first thing a neurologist will start them on – and it’s sometimes a selling point to the parent that the time spent waiting for a referral to a neurologist is not waste – they will actually be in better shape and can move things along faster.  It also gives them some sens of control of what can be a draining situation. Summary and Mental Road Map If you were thinking meningitis or acute bleed, especially with fever or meningismus, get a CT first if you see signs of increased intracranial pressure, or if there is an abnormal neuro exam. Otherwise go straight to the lumbar puncture (LP). In the afebrile child with a normal exam, give symptomatic relief, briefly counsel them, and arrange for follow-up. In the afebrile child with an abnormal exam, obtain a CT in the ED. If negative, either admit for MRI if you are still concerned, or consider LP for idiopathic intracranial hypertension (pseudotumor cerebri). Talk with parents early about expectations, and offer them some friendly advice on prevention. Refer patients to the primary care provider or neurologist if the presentation is more involved. After a good history and physical examination in the ED that results in no red flags, we have time on our side. Help the family through the process by explaining the next steps and what can be done in the meantime. Compassion and a plan: sometimes these are our most powerful allies.   References Ajiboye N et al. Cerebral Arteriovenous Malformations: Evaluation and Management. Scientific World J. 2014; vol 2014. Bachur RG, Monuteaux MC, Neuman MI. A comparison of acute treatment regimens for migraine in the emergency department. Pediatrics. 2015 Feb;135(2):232-8. doi: 10.1542/peds.2014-2432. Chiappedi M, Balottin U. Medication overuse headache in children and adolescents. Curr Pain Headache Rep. 2014 Apr;18(4):404. doi: 10.1007/s11916-014-0404-9. Curtis S, Stobart K, Vandermeer B, Simel DL, Klassen T. Clinical features suggestive of meningitis in children: a systematic review of prospective data. Pediatrics. 2010;126(5):952-60. Gonzalez LF, Bristol RE, Porter RW, Spetzler RF. De novo presentation of an arteriovenous malformation. Case report and review of the literature. J Neurosurg. 2005 Apr;102(4):726-9. Kaar CR, Gerard JM, Nakanishi AK. The Use of a Pediatric Migraine Practice Guideline in an Emergency Department Setting. Pediatr Emerg Care. 2016 Jul;32(7):435-9. doi: 10.1097/PEC.0000000000000525. Lewis DW, Ashwal S, Dahl G, Dorbad D, Hirtz D, Prensky A, Jarjour I; Quality Standards Subcommittee of the American Academy of Neurology; Practice Committee of the Child Neurology Society. Practice parameter: evaluation of children and adolescents with recurrent headaches: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2002 Aug 27;59(4):490-8. Lewis D, Ashwal S, Hershey A, Hirtz D, Yonker M, Silberstein S; American Academy of Neurology Quality Standards Subcommittee; Practice Committee of the Child Neurology Society.Practice parameter: pharmacological treatment of migraine headache in children and adolescents: report of the American Academy of Neurology Quality Standards Subcommittee and the Practice Committee of the Child Neurology Society.Neurology. 2004 Dec 28;63(12):2215-24. Medina LS, Kuntz KM, Pomeroy S. Children With Headache Suspected of Having a Brain Tumor: A Cost-Effectiveness Analysis of Diagnostic Strategies. Pediatrics. 2001;108(2):255-63. Richer L, Billinghurst L, Linsdell MA, Russell K, Vandermeer B, Crumley ET, Durec T, Klassen TP, Hartling L. Drugs for the acute treatment of migraine in children and adolescents. Cochrane Database Syst Rev. 2016 Apr 19;4:CD005220. Stewart WF, Lipton RB, Celentano DD, Reed ML. Prevalence of migraine headache in the United States. JAMA. 1992;267:64-69. Tascu A et al. Spontaneous intracranial hemorrhage in children – ruptured lobar arteriovenous malformations: report of two cases. Romanian Neurosurgery. 2015; 29(23) 1: 85-89. This post and podcast are dedicated to Mark Wilson, PhD, BSc, MBBChir, FRCS(SN), MRCA, FIMC, FRGS for his #FOAMed generosity, candor, humility, and dedication to the care of the acutely ill and injured. Thank you. Pediatric Headache Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP

Have you ever been in any of these situations? ⇒   You have a stable child who just needs fluids, but no laboratory tests ⇒   You’ve tried PO hydration, to no avail, despite anti-emetics ⇒   You’re poking the stable, but dehydrated child repeatedly without success What now? Hypodermoclysis, otherwise known as subcutaneous rehydration. [Insert Player] Clysis comes from the same Greek word that “a flood” – hypodermoclysis refers to flooding the subcutaneous space with fluid, so that it can be absorbed systemically. Sound far-fetched? Well, it turns out, what is old is new again. In 1913, Dr Day first described this technique for a child with severe diarrhea who could not tolerate fluids by mouth. Hypodermoclysis then began to gain popularity with a peak of use in the 1940s, until an innovative breakthrough in 1950. Dr David Massa, a resident anesthesiologist at the Mayo clinic, invented the first catheter-over-needle apparatus. With increasing safety and ready access of IV catheters, IV quickly overshadowed SC. The subcutaneous route of hydration has also been used effectively in geriatric and palliative care for decades, and it is only now beginning to gain popularity again in its original population: children. So, how does it work? In a nutshell, you place a butterfly needle or angiocatheter in the subcutaneous space and you run fluids into it. The tissues quickly absorb the fluids, making them available systemically. That’s it. Everything else is just finesse. The ideal candidate for hypodermoclysis is the stable patient, with mild to moderate dehydration who fails a trial of fluids by mouth, or who needs a bridge to gaining IV access later, after a slow subcutaneous fluid bolus is given. Ok, so how do you do it? Place a topical anesthetic cream, such as EMLA, cover with occlusive dressing (IV dressing), wait 15-20 min "Pinch an inch" of skin anywhere, but the most practical site in young children is between the scapulae Insert a 25-gauge butterfly needle or 24-gauge angiocatheter (preferred by the author), secure Inject 150 U hyaluronidase SC, if available Infuse 20 mL/kg isotonic solution over one hour, repeat as needed or use "bolus" as bridge to IV access You can set the line to gravity, and if it is dripping in, you may leave it be. If you see a very slow drip by gravity, or worse, nothing is dripping, you can set the line on a pump, to deliver up to 20 mL/kg over an hour. Infusion at this rate optimizes the balance we want in minimal discomfort while maximizing the flow rate. This is not a “bolus” in the true sense – but then, when you compare it to the alternative – like IV therapy – and we see a time and cost savings.  Dr Mace and colleagues in the American Journal of Emergency Medicine report substantially decreased cost and ED length of stay when comparing the material and human resources needed to place an IV in a squirmy young child, compared with a simple subcutaneous stick. There will be swelling There will be swelling – that is the goal. It is really painless, and your patient may lie down on his back with the pump going – it is actually pretty comfortable for most children and adults to do. Here’s a tip – since there will be swelling, we want to be careful about how we secure the line, so how you tape it down to the skin is important – we want to avoid a pulling sensation, which can be the beginning of the end of the tolerance for the procedure.  Cover that with an occlusive dressing, as you would an IV site. The footprint of the occlusive dressing is relatively small, so it will travel up on top of the subcutaneous mound you’re creating. As the line exits the occlusive patch, place a thin layer of gauze between the skin and the IV tubing, so that the tubing doesn’t press into the skin. Then—as far away from the puncture site as possible—tape it down securely. The idea is not to tape on the growing mound itself, because the mound may pull at the anchored skin and set a nuclear chain reaction of annoyance and restlessness – and potentially a failed procedure. The swelling will look indurated, a pinkish red.  It’s not an allergic reaction: even with the old preparations of hyaluronidase, allergic reactions were rare, and now they are very rare with the recombinant preparation. It is supposed to swell and look ugly. The subcutaneous tissues will swell to a point where you have a steady state fluid administration rate, and as soon as you stop the infusion, the remaining fluid will start to subside as it is absorbed. A Bridge to IV Therapy? Kuensting et al. in the Journal of Emergency Nursing in 2013 compared subcutaneous fluid infusion with intravenous fluid infusion in children with difficult IV access. They found the mean time from order entry to subcutaneous fluid infusion to be 20 min, compared to the failed IV access group with an average infusion start time of 1.5 hours. The latter group eventually received subcutaneous fluids.  The investigators also found a shorter ED length of stay in the subcutaneous group. In the same study, a subgroup received subcutaneous fluids initially, and later an IV. They found a trend in ease of IV access after subcutaneous fluid therapy. In other words, if your little patient with difficult IV access is hemodynamically stable and amenable to a bolus over an hour, you may choose to start with hypodermoclysis and reevaluate. Predicting Difficult IV Access in Children Much has been studied and written about the predictors of difficult IV access in children. The most often cited are: age < 3 years, weight less than 5 kg, prematurity, obesity, and darker skin tones, where the contrast of vein to skin may not be so apparent. The three main predictors of the score validated by Riker et al. in Annals of Emergency Medicine include the most practical and universal of features: vein palpability, vein visibility, and patient age. If you’re anticipating difficult IV access in the child who can stand to wait an hour for a slow bolus, you may start with the subcutaneous route to get those veins plumper and more visible, to improve your chances of IV access in the very near future. Medications via Subcutaneous Route Certain medications have been used safely via subcutaneous infusion; always check dose, rate, and compatibility.   What about catheter size? You don’t need to use larger needles or angiocathters for older children, adolescents or adults. A 25-gauge butterfly or 24-gauge angiocatheter works well from an infant to an elder. In one study of adults, a half a liter of saline was infused by gravity via a 24-gauge catheter. With IVs, the shorter and larger the bore, the faster the infusion. In subcutaneous infusion, it is not the size of the catheter, but the osmotic gradient that determines the rate of absorption. What if I don't have that fancy hyaluronidase? It’s actually increasingly readily found – and available in generic form. If you have it, please use it – it will make a believer out of you and others. Hypodermoclysis will work without hyaluronidase – the process of subcutaneous rehydration just takes a lot longer to work. In a double-blind cross-over trial Thomas et al. in 2007 compared subcutaneous administration of lactated ringer’s solution by gravity with and without hyalurondase. The hyaluronidase group received their fluids 5 times faster. The average rate of the hyaluronidase group was 382 mL/h versus the fluid only group, who did not receive hyalurinodase; they were substantially slower, at 82 mL/h. It’s worth using if you have it, but still potentially useful if you don’t. Recap: Supplies √    EMLA or any topical anesthetic used for intact skin, placed as soon as the decision is made √    A 25-gauge butterfly needle or 24-gauge angiocatheter √    IV tubing, gauze to pad, tape to anchor √    150 U hyaluronidase, the same dose, regardless of age or size √    Isotonic fluids – you can start with 20 ml/kg √    And finally a well informed team made up by the patient, the parents, and your staff, so that everyone knows what to expect for a successful subcutaneous fluid administration. References Allen CH, Etzwiler LS, Miller MK, Maher G, Mace S, Hostetler MA, Smith SR, Reinhardt N, Hahn B, Harb G; INcreased Flow Utilizing Subcutaneously-Enabled Pediatric Rehydration Study Collaborative Research Group. Recombinant human hyaluronidase-enabled subcutaneous pediatric rehydration. Pediatrics. 2009 Nov;124(5):e858-67. Bruno VG. Hypodermoclysis: a literature review to assist in clinical practice. Einstein (Sao Paulo). 2015 Jan-Mar;13(1):122-8. Cabañero-Martínez MJ, Velasco-Álvarez ML, Ramos-Pichardo JD, Ruiz Miralles ML, Priego Valladares M4, Cabrero-García J. Perceptions of health professionals on subcutaneous hydration in palliative care: A qualitative study. Palliat Med. 2016 Jun;30(6):549-57. Kuensting LL. Comparing subcutaneous fluid infusion with intravenous fluid infusion in children. J Emerg Nurs. 2013 Jan;39(1):86-91. Mace SE, Harb G, Friend K, Turpin R, Armstrong EP, Lebel F. Cost-effectiveness of recombinant human hyaluronidase-facilitated subcutaneous versus intravenous rehydration in children with mild to moderate dehydration. Am J Emerg Med. 2013 Jun;31(6):928-34. O'Hanlon S, Sheahan P, McEneaney R. Severe hemorrhage from a hypodermoclysis site. Am J Hosp Palliat Care. 2009 Apr-May;26(2):135-6. Remington R, Hultman T. Hypodermoclysis to treat dehydration: a review of the evidence. J Am Geriatr Soc. 2007 Dec;55(12):2051-5. Riker MW, Kennedy C, Winfrey BS, Yen K, Dowd MD. Validation and refinement of the difficult intravenous access score: a clinical prediction rule for identifying children with difficult intravenous access. Acad Emerg Med. 2011 Nov;18(11):1129-34. Rouhani S, Meloney L, Ahn R, Nelson BD, Burke TF. Alternative rehydration methods: a systematic review and lessons for resource-limited care. Pediatrics. 2011 Mar;127(3):e748-57. Smith LS. Hypodermoclysis with older adults. Nursing. 2014 Dec;44(12):66. Spandorfer PR. Subcutaneous rehydration: updating a traditional technique. Pediatr Emerg Care. 2011;27(3):230-6. Thomas JR, Yocum RC, Haller MF, von Gunten CF. Assessing the role of human recombinant hyaluronidase in gravity-driven subcutaneous hydration: the INFUSE-LR study. J Palliat Med. 2007 Dec;10(6):1312-20. Vacha ME et al. The Role of Subcutaneous Ketorolac for Pain Management. Hosp Pharm. 2015 Feb; 50(2): 108–112. Zaloga GP, Pontes-Arruda A, Dardaine-Giraud V, Constans T; Clinimix Subcutaneous Study Group. Safety and Efficacy of Subcutaneous Parenteral Nutrition in Older Patients: A Prospective Randomized Multicenter Clinical Trial. J Parenter Enteral Nutr. 2016 Feb 17. pii: 0148607116629790. [Epub ahead of print]   This post and podcast are dedicated to Christina L. Shenvi, MD, PhD, for her dedication to excellence in patient care and enthusiasm in #FOAMed, Emergency Medicine, and Geriatric Emergency Medicine.  There are many shared lessons learned in the care of children, elders, and families.  Thank you. Catch Dr Shenvi on the innovative GEMcast. Subcutaneous Infusion Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP

Pearls from our conference discussing apparent life-threatening events (ALTE). https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_16_Final.m4a Download Leave a Comment Tags: ALTE, Pediatrics Show Notes Shownotes Mittal MK et al. A clinical decision rule to identify infants with apparent life-threatening event who can be safely discharged from the emergency department. Pediatr Emerg Care 2012; 28(7): 599-605. PMID: 22743742 Kaji AH et al. Apparent life-threatening event: multi center prospective cohort study to develop a clinical decision rule for admission to the hospital. Ann Emerg Med 2013; 61(4): 379-87. PMID: 23026786 Read More

Pearls from our conference discussing apparent life-threatening events (ALTE). https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_16_Final.m4a Download Leave a Comment Tags: ALTE, Pediatrics Show Notes Shownotes Mittal MK et al. A clinical decision rule to identify infants with apparent life-threatening event who can be safely discharged from the emergency department. Pediatr Emerg Care 2012; 28(7): 599-605. PMID: 22743742 Kaji AH et al. Apparent life-threatening event: multi center prospective cohort study to develop a clinical decision rule for admission to the hospital. Ann Emerg Med 2013; 61(4): 379-87. PMID: 23026786 Read More

Pearls from our conference discussing apparent life-threatening events (ALTE). https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_16_Final.m4a Download Leave a Comment Tags: ALTE, Pediatrics Show Notes Shownotes Mittal MK et al. A clinical decision rule to identify infants with apparent life-threatening event who can be safely discharged from the emergency department. Pediatr Emerg Care 2012; 28(7): 599-605. PMID: 22743742 Kaji AH et al. Apparent life-threatening event: multi center prospective cohort study to develop a clinical decision rule for admission to the hospital. Ann Emerg Med 2013; 61(4): 379-87. PMID: 23026786 Read More

Do you have a plan for your little patient when he just won’t stop seizing?  What do you do when your typical treatment is not enough? Get up-to-date in the understanding and management of pediatric status epilepticus. Definition of status epilepticus:Continuous seizure activity of 5 minutes or greater – OR – Recurrent activity without recovery between intervals.  (This definition includes clinically apparent seizures as well as those seen only on EEG.) During a seizure, GABA receptors in the neuron’s membrane are internalized and destroyed.  Seizure activity itself starts this self-defeating process – this is the first reason we need to act as quickly as possible and take advantage of the GABA receptors that are still recruitable. Excitatory receptors – the NMDA receptors – are acutely upregulated and mobilize to the neuron’s surface.  This is the second reason to act quickly and avoid this kindling effect. In other words – time is brain. Or… is it something else as well? Pediatric status epilepticus is analogous to the multi-organ dysfunction syndrome in severe sepsis.  Status epilepticus affects almost every organ system.  Cardiac – dysrhythmias, high output failure, and autonomic dysregulation resulting in hypotension or hypertension.  Respiratory – apnea and hypoxia, ARDS, and potentially aspiration pneumonia.  Renal – rhabdomyolysis, myoglobinuria, and acute renal failure. Metabolic – lactic acidosis, hypercapnia, hyperglycemia, sometimes hypoglycemia, hyperkalemia, and leukocytosis. Autonomic – hyperpyrexia and breakdown of cerebral circulation.  DeLorenzo et al.: Mortality correlated with time seizing.  Once the seizure has met the 30 min mark, Delorenzo reported a jump from 4.4% mortality to 22%!  If the seizure lasts greater than 2 hours, 45%.  Time spent seizing is a vicious cycle: it’s harder to break the longer it goes on, and the longer it goes on, the higher the mortality. Think about treatment of pediatric status epilepticus in terms of time: prehospital care, status epilepticus (greater than 5 min), initial refractory status epilepticus (greater than 10 min), later refractory status (at 20 min), and coma induction (at 25 minutes). Case 1: Hyponatremic Status Epilepticus Give 3 mL/kg of 3% saline over 30 min. Stop the infusion as soon as the seizure stops. Case 2: INH toxicity Empiric treatment -- you are the test.  If we know the amount of ingestion in adults or children, we give a gram-for-gram replacement, up to 5 grams.  If a child under 2 years of age arrives to you in stats epilepticus, give 100 mg of IV pyridoxime for potentially undiagnosed congenital deficiency. Case 3: Headache and Arteriovenous Malformation Unlike in adults, stroke in children is divided evenly between hemorrhagic and ischemic etiologies.  The differential is vast: cardiac, hematologic, infectious, vascaulr, syndromic, metabolic, oncologic, traumatic, toxic.  Treatment: stabilization, embolization by interventional radiology, elective extirpation when more stable.  Other options for stable patients include an endovascular flow-directed microcatheter using cyanoacrylate. Radiosurgery is an options for others. Non-convulsive Status Epilepticus Risk factors include age < 18, especially age < 1, no prior history of seizures, and traumatic brain injury.  This would prompt you to ask for continuous EEG monitoring for non-convulsive status epilepticus, especially when there is a change in mental status for no other reason.  Also, a prolonged post-ictal state or prolonged altered mental status.  Other considerations are those who had a seizure and cardiac arrest -  ROSC without RONF, those with traumatic brain injury, and those needing ECMO – all within the context of seizures. SUMMARY POINTS The longer the seizure lasts, the harder it is to break – act quickly Have a plan for normal escalation of care, and Search for an underlying cause Recognize when the routine treatment is not enough.Before You Go “Healing is a matter of time, but it is sometimes also a matter of opportunity.” “Extreme remedies are very appropriate for extreme diseases.”  – Hippocrates of KosSelected References Abend NS et al. Nonconvulsive seizures are common in critically ill children. Neurology. 2011; 76(12):1071-7 Baren J. Pediatric Seizures and Strokes: Beyond Benzos and Brain Scans. ACEP Scientific Assembly. October 8th, 2009. Boston, MA. Brophy et al. Guidelines for the Evaluation and Management of Status Epilepticus. Neurocrit Care. 2012; DOI 10.1007/s12028-012-9695-z Capovilla G et al. Treatment of convulsive status epilepticus in childhood: Recommendations of the Italian League Against Epilepsy. Epilepsia. 2013; 54 Suppl 7:23-34 Chin RFM et al., for the NLSTEPSS Collaborative Group. Incidence, cause, and short-term outcome of convulsive status epilepticus in childhood: prospective population-based study. Lancet. 2006; 368: 222–29. Chen JW, Chamberlain CG. Status epilepticus: pathophysiology and management in adults. Lancet Neurol. 2006; 5:246-256. DeLorenzo RJ. Comparison of status epilepticus with prolonged seizure episodes lasting from 10 to 29 minutes. Epilepsia. 1999 Feb;40(2):164-9. LaRoche SM, Helmers SL. The New Antiepileptic Drugs: Scientific Review. JAMA. 2004;291:605-614. Minns AB, Ghafouri N, Clark RF. Isoniazid-induced status epilepticus in a pediatric patient after inadequate pyridoxine therapy. Pediatr Emerg Care. 2010; 26(5):380-1. Ogilvy CS et al. Recommendations for the Management of Intracranial Arteriovenous Malformations: A Statement for Healthcare Professionals From a Special Writing Group of the Stroke Council, American Stroke Council. Stroke. 2001; 32: 1458-1471 Rosati A et al. Efficacy and safety of ketamine in refractory status epilepticus in children. Neurology. 2012; 79:2355-2358. Schwartz ID. Hyponatremic seizure in a child using desmopressin for nocturnal enuresis.  Arch Pediatr Adolesc Med. 1998 Oct;152(10):1037-8 Trommer BL, Pasternak JF.  NMDA receptor antagonists inhibit kindling epileptogenesis and seizure expression in developing rats. Brain Res Dev Brain Res. 1990 May 1;53(2):248-52. Waterhouse EJ et al. Prospective population-based study of intermittent and continuous convulsive status epilepticus in Richmond, Virginia. Epilepsia. 1999 Jun;40(6).