Pediatric Emergency Playbook

You make tough calls when caring for acutely ill and injured children. Join us for strategy and support, through clinical cases, research and reviews, and best-practice guidance in our ever-changing acute-care landscape. This is your Pediatric Emergency Playbook.

From the Ashes of SIRS: The Phoenix Sepsis Score 06/01/2024

Torticollis 03/01/2024

Resuscitative Umbilical Vein Catheterization 12/01/2023

Update 2023 09/01/2023

Neonatal Resuscitation 08/01/2023

Stridor, Stertor, and Noisy Breathing 07/01/2023

Brief, Huddle, and Debrief in the PED 06/01/2023

Fontanelle Facts 05/01/2023

Wound Care at Home 04/01/2023

The Abdominal Exam in Children 03/01/2023

Hemolytic Uremic Syndrome 02/01/2023

Push-Dose Epi 01/01/2023

Environmental Injuries in Children 12/01/2022

PEM Myths 11/01/2022

Palms and Soles 10/01/2022

The Febrile Infant 09/01/2022

Animal Bites in Children 08/01/2022

Focus On: Maneuvers for Murmurs 07/01/2022

Pathologic Murmurs in Children 06/01/2022

Benign Murmurs in Children 05/01/2022

The Newborn and Infant Neuro Exam 04/01/2022

Eczema 03/01/2022

Sickle Cell Complications 02/01/2022

Focus On: Pyloric Stenosis 01/01/2022

Focus On: Pyloric Stenosis Myth: “No olive, no problem” Reality: Rare finding, since we diagnose earlier Pyloric stenosis occurs in young infants because the pyloric sphincter hypertrophies, causing near-complete obstruction of the gastric outlet. More common in boys, preterm babies, first-born. Less common in older mothers. Association with macrolide use. Presentation Young infant arrives with forceful vomiting, but can’t quite get enough to eat “the hungry, hungry, not-so-hippo”. Early presentation from 3 to 5 weeks of age: projectile vomiting Later presentation up to 12 weeks: dehydration, failure to thrive, possibly the elusive olive Labs may show hypOchloremic, hypOkalemic metabOlic acidosis: “all the Os” Watch out for hyperbilirubinemia, the “icteropyloric syndrome”: unconjugated hyperbilirubinemia from dehydration. Ultrasound shows a pylorus of greater than 3 mm wide and 14 mm long. Memory aid: 3.14 is “pi”. In pyloric stenosis, π-lorus > 3 x 14 Treatment Various options, may be deferred depending on age, availability, severity of illness, including: Pyloromyotomy — definitive. The Ramstedt pyloromyotomy is an open procedure and involves a involves a longitudinal incision along the pylorus, and blunt dissection just to level of the submucosa. The laparoscopic approach (umbilicus) is less invasive but may convey an increased risk of incomplete relief of the obstruction or perforation through the mucosa. Also, this approach involves longer OR and anesthesia time. Endoscopic balloon dilation – not as effective as pyloromyotomy; reserved for poor surgical candidates. Conservative management — an NG tube is passed by IR, and the infant slowly feeds and “grows out of it”. Atropine is sometimes used to relax the pyloric sphincter. Also usually reserved for poor surgical candidates. Selected references Aboagye J, Goldstein SD, Salazar JH, Papandria D, Okoye MT, Al-Omar K, Stewart D, Lukish J, Abdullah F. Age at presentation of common pediatric surgical conditions: Reexamining dogma. J Pediatr Surg. 2014 Jun;49(6):995-9. Bakal U, Sarac M, Aydin M, Tartar T, Kazez A. Recent changes in the features of hypertrophic pyloric stenosis. Pediatr Int. 2016 May;58(5):369-71. Sharp WW, Chan W. Images in emergency medicine. Infant with projectile vomiting. Peristaltic abdominal waves associated with infantile hypertrophic pyloric stenosis. Ann Emerg Med. 2014 Mar;63(3):289,308. Staerkle RF, Lunger F, Fink L, Sasse T, Lacher M, von Elm E, Marwan AI, Holland-Cunz S, Vuille-Dit-Bille RN. Open versus laparoscopic pyloromyotomy for pyloric stenosis. Cochrane Database Syst Rev. 2021 Mar 9;3(3):CD012827. /episode/index/show/pemplaybook/id/21137966

Pediatric Vital Signs: What Are We Missing? 12/01/2021

Focus On: Gun Shot Wounds in Children 11/01/2021

Syndromes You Should Know 10/01/2021

Focus On: Inguinal Hernias in Children 09/01/2021

Focus On: Inguinal Hernias in Children Hernia Myth: “If it’s not strangulated, it’s elective” Reality: Unlike in adults, all hernias in children are repaired at the time of diagnosis because: The risk of incarceration and strangulation is high There is a 30% risk of testicular infarction due to pressure on the gonadal vessels It is not worth messing around and “trying to navigate the system” Most groin hernias in children are indirect inguinal hernias (incomplete closure of processus vaginalis). Most indirect hernias are in boys (10-fold risk), and on the right (60%). Premature babies are at higher risk as well. 15% are bilateral. Hernias often bulge further with crying. For infants, in supine position, gently restrain their feet on the gurney. They hate it and will cry. For older children, have them laugh, cough, or blow through a syringe. The “silk glove sign” is not reliable, but if found is highly suggestive of an inguinal hernia. Roll the cord structures across the pubic tubercle. If you feel catching, like two sheets of silk rubbed together, this suggests edema from the patent processus vaginalis. Most (80%) incarcerated hernias can be reduced initially and admitted for surgery 24-48 hours after edema has improved. Use age- and patient-appropriate sedation and reduce if no peritonitis or concern for strangulation. Hydroceles usually are: non-communicating (with the abdomen); worse with crying or during the day; improve by morning; and self-resolve by age 2 without intervention. Communicating hydroceles are: usually present at birth; are associated with a patent processus vaginalis; and are often repaired later, if not resolved by 1 or 2 years of age. Girls may have an ovary incarcerated in hernial sac. Open repair or laparoscopic techniques are used. The laparoscope offers visualization of the contralateral side without significant risk of injury to vas deferens. A metachronous hernia develops later on the other side. Some surgeons opt to explore both sides at the time of diagnosis, others take conservative approach (small risk of fertility issues if both are open-explored) My take: regardless of presentation, needs admission Selected References Abdulhai S, Glenn IC, Ponsky TA. Inguinal Hernia. Clin Perinatol. 2017 Dec;44(4):865-877 Brandt ML. Pediatric hernias. Surg Clin North Am. 2008 Feb;88(1):27-43, vii-viii. doi: 10.1016/j.suc.2007.11.006. Esposito C, Escolino M, Cortese G, Aprea G, Turrà F, Farina A, Roberti A, Cerulo M, Settimi A. Twenty-year experience with laparoscopic inguinal hernia repair in infants and children: considerations and results on 1833 hernia repairs. Surg Endosc. 2017 Mar;31(3):1461-1468. Olesen CS, Mortensen LQ, Öberg S, Rosenberg J. Risk of incarceration in children with inguinal hernia: a systematic review. Hernia. 2019 Apr;23(2):245-254 /episode/index/show/pemplaybook/id/20249405

Focus On: Pediatric Emergency Eye Exam 08/01/2021

Focus On: Breath Holding Spells 07/01/2021

Pediatric Emergency Playbook

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