Things I learned this week - Paediatrics 1

1. Headache in Children

2. Using Paracetamol as an Anti-emetic

3. Croup - Clinically relevant classification from PedsEM Morsels

4. Diagnosing and Treating Constipation in Children

5. Fever phobia RANT

Posted by:

              

     Lakshay Chanana

     Emergency Medicine Trainee

     South East Scotland Deanery
     Edinburgh

     @EMDidactic

Greenstick and Torus fractures

Torus Fractures (Buckle/Cortical Fractures)

Torus fracture is an injury of the cortex on the non-compressive side of the bone with an intact cortex on the tension side. Torus is derived from Latin (tori) meaning a swelling or protuberance. Deformity should not occur in torus fracture because the periosteum and cortex are intact on the side of the bone opposite to fracture. The distal end of the radius is the most common site for a torus fracture. Compressive forces often result in a bulging or buckling of the periosteum rather than a more complete fracture line. these injuries usually involve the metaphysis. A simple torus fracture will not produce a visible deformity to the shape of the extremity; however, there is typically soft tissue swelling and point tenderness over the bony injury. 

Radiographically, the torus fracture may be subtle. Carefully inspect the contour of the metaphyseal flare. Any asymmetry, bulging, or deviation of the cortical margin indicates a torus fracture. Soft tissue swelling is also usually evident. Torus fractures are not associated with angulation, displacement, or rotational abnormalities, so reduction is not necessary. Treat by splinting in a position of function fracture clinic follow-up within 1 week. 

https://radiopaedia.org/cases/torus-fracture-1

Greenstick Fractures
A greenstick fracture is characterized by cortical disruption and periosteal tearing on the convex side of the bone, with an intact periosteum on the concave side of the fracture. Greenstick fractures are more stable and somewhat less painful than complete fractures because the area of intact periosteum limits bony displacement. The need for reduction is determined by the degree of angulation of the fracture, the age of the child, and the anatomic location of the injury.

https://radiopaedia.org/cases/radius-and-ulna-greenstick-fractures

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

Paediatric Head Trauma

Head injury in a common presentation in children and 0 to 4 years of age is the most commonly affected group. The vast majority of head trauma is caused by blunt force (assaults, abuse, Non-Accidental Injury). t is estimated that only about 5% have an intracranial injury, and <1% of those with intracranial injury require surgical intervention. Clinically significant injuries are rare in children and thus it is a challenge to conclude who needs imaging. Head injuries resulting in a GCS score of ≤8 are severe, those with scores of 9 to 13 are moderate, and those with scores of 14 or 15 are mild. 

Head Injury Pattern in children

• In children, diffuse injuries are proportionally more common whereas, in adults, focal injuries such as epidural and subdural hematomas and cerebral contusions are more common.
• Compared to adults, skull fractures in children are more common but less frequently associated with underlying brain injury.
• A growing fracture can present months on the injury and requires neurosurgical repair.  It can occur when the leptomeninges are torn beneath the fracture, leading to a CSF leptomeningeal cyst that forces apart the fracture edges and leads to nonunion. Growing skull fractures typically present weeks to months following an injury resulting in skull fracture. 

Specific Injuries 
Epidural hematoma - Collection of blood between the inner skull and the dura. Usually results from rapid arterial bleeding from the middle meningeal artery or the dural or diploic vasculature. Generally good prognosis if surgical evacuation can be done in a timely fashion. 

Subdural hematomas - More common than epidural hematomas in children. Bleeding results from the tearing of the subdural veins. These injuries are frequently associated with underlying brain injury and have a worse prognosis. 

Subarachnoid hemorrhage - Often associated with significant trauma and diffuse axonal injury (DAI). Children with DAI present with a depressed level of consciousness with a normal appearing CT scan. 

Cerebral contusions are located in the cortex underlying the area of direct impact (coup lesions) or on the opposite side (contrecoup lesions). 

History and Physical
Mechanism, Time of the incident
Any Witness
LOC, seizure, changes in behavior, or vomiting, ENT Bleed
Medications, Previous Head trauma
Suspect NAI if the history is incompatible with the child’s age 

Particularly in the young child, symptoms of neurologic injury may be subtle. Lethargy, irritability, seizures, and alterations in muscle tone or level of consciousness, as well as vomiting, poor feeding, breathing abnormalities and apnea, raise the suspicion of significant head injury.

Assessment

• ABCs
• GCS
• Pupils
• Head - Inspect, Palpate, Check Fontanelles 
• ENT Exam
• Maxillofacial Exam
• Neck exam 
• Quick Head to toe exam

The big question is about when to image and when to observe? Most of us are minimalists when it comes to imaging in children as ionizing radiation is a long-term carcinogen. 

There are several clinical decisions rules have been developed to guide imaging. 

1. CHALICE (Children’s Head Injury Algorithm for the Prediction of Important Clinical Events)
2. CATCH (Canadian Assessment of Tomography for Childhood Head Injury)
3. PECARN (Pediatric Emergency Care Applied Research Network)
4. NICE guidelines 

PECARN is considered the “best for children and infants, with the largest cohort, highest sensitivity and acceptable specificity of clinically significant  injury

Take Home:

Head injuries requiring surgical intervention are rare in children. Most of them need reassurance and good discharge advise. Be mindful of the various clinical decision rules for risk stratification. 

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

Headache in children - ED management

Headache is a rare chief complaint in children but more frequently seen in adolescents. ED evaluation should answer the following the questions:

• Primary or Secondary Headache?
• Needs Investigations or Imaging?
• Need for follow up with GP?

Primary headaches (Disabling): Migraine, Tension Headache, Cluster headache (and other trigeminal autonomic cephalalgias); and other primary headaches (such as cough or exertional headache). They are thought to be due to a primary malfunction of neurones. Primary headaches are typically self-limited.

Secondary headaches (a/w Morbidity and Mortality): May show up symptomats of some underlying pathology, e.g. from raised intracranial pressure and space-occupying lesions. Headaches due to a SOL are worse when lying down and morning vomiting is characteristic. There is often a change in mood, personality or educational performance. Causes of secondary headache include brain tumors, vascular malformations, and intracranial abscesses; craniofacial problems, such as sinusitis, dental abscesses, or otitis; systemic disorders, such as lupus cerebritis; and exposure to toxic substances, such as carbon monoxide, lead, or cocaine. Other features suggestive of a space-occupying lesion are i.e Red Flags for Headache:

• Visual field defects – from lesions pressing on the optic pathways, e.g. craniopharyngioma (a pituitary tumour)
• Cranial nerve abnormalities causing diplopia, new-onset squint or facial nerve palsy. Abducens nerve has a long intracranial course and is often affected when there is raised pressure, resulting in a squint with diplopia and inability to abduct the eye beyond the midline. It is a false localising sign. Other nerves are affected depending on the site of lesion, e.g. pontine lesions may affect the VIIth (facial) cranial nerve and cause a facial nerve palsy.
• Abnormal gait (Cerebellar Lesions)
• Torticollis 
• Bradycardia
• Confusion, Seizures
• Growth failure, e.g. craniopharyngioma or hypothalamic lesion
• Papilloedema 
• Cranial bruits – may be heard in arteriovenous malformations 
• Recent change in personality, behaviour or educational performance
• Headache that wakes up a child (different from headache on awakening, not uncommon in migraine)

Headache coinciding with the onset of fever suggests inflammation - sinusitis, pharyngitis, otitis, or meningitis), or may be associated with a more general viral syndrome. The severity of a headache is not helpful to determine the cause. Patients with tension headaches can com- plain of terrible pain, whereas a child with a brain tumor may complain of mild to moderate pain. Nonetheless, complaints of very intense pain should be taken seriously and assessed in context with other historical elements.

The most common causes of headache in chidren are viral and respiratory illnesses and migraneous headaches. A migraine that lasts >72 hours is known as status migrainosus. 

• The mainstay of management is a thorough history and examination. Imaging is unnecessary in the absence of any Red Flag features.
• Among children with intracranial diseases, most are unable to indicate the location of the pain or had an occipital headache. 
• Positional preferences --> space- occupying lesions
• Abdominal pain, nausea, or vomiting--> May be seen in migraine 
• Cluster headaches can be associated with multiple ipsilateral symptoms
• Headache with effortless vomiting but no GI complaints --> suggests elevated ICP
• Family history is commonly seen in migraneous headaches

Examination findings may be normal even if the history suggests a secondary headache. A careful neurologic examination with attention to cranial nerves, gait, strength, and mental status is essential to exclude secondary headache. There is a very low incidence of positive findings on neuroimaging studies in children with headache who have normal findings on physical examination.

Imaging CT or MRI - NCCT is sufficent for most cases that require imaging. CT with contrast is needed when you suspect brain abscess but a normal head CT does not exclude an intracranial mass because the posterior fossa is not well visualized. The posterior fossa is the most common location of brain tumors in children, and MRI of the brain provides better visualization of the posterior fossa. MRA/MRV are useful when vascular malformations or dural sinus thrombosis is suspected. 

Treatment

Do not use narcotics for primary headaches. Long-term use of narcotics can change the pain-modulatory system leading to more intense pain. 

Options: 

• Primary Headaches - Fluid bolus/NSAIDs, Stemetil or Metoclopermide. Metocloperamide and Stemetil can cause extrapyramidal reactions, which are relieved by diphenhydramin, Triptans High Flow Oxygen can also be used to treate Cluster HA.  
• Secondary Headaches need symtom control with Analgesics and further evaluation. 

Take Home:

The mainstay of management is a thorough history and examination. Imaging is unnecessary in the absence of any Red Flag features.

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

Children with tLOC

Children presenting with syncope usually suffer from benign causes and about 80% constitute vasovagal or neuro cardiogenic syncope. From an etiological perspective, syncope in children can be divided into four likely causes:

1. Cardiovascular (tachydysrhythmias, bradydysrhythmias, outflow obstruction, and myocardial dysfunction)
2. Neurologic 
3. Metabolic 
4. Other Benign entities (Vasovagal - reduced venous return)

A prodrome of warmth, nausea, lightheadedness, and a visual gray-out is indicative of neurocardiogenic syncope. Routine laboratory studies are not needed in such cases.

Involuntary motor movements due to transient cerebral hypoxia may occur in syncopal events which may be reported as fits by laypersons. Syncope related myoclonus is generally seen after loss of consciousness (seizure-related movements are seen prior to the loss of consciousness), less rhythmic nature, and are of shorter duration. 

Red Flags for Pediatric Syncope:

• Onset with Exertion
• History of Cardiac Disease
• Heart Murmur on examination
• Family h/o Sudden Deaths or arrhythmias
• Associated chest pain/palpitations
• Syncope in Recumbent position
• Recurrent episodes
• Use of Cardiac medications
• No prodrome  
• Prolonged LOC

Exertion before a syncopal event increases the suspicion of structural heart disease, specifically cardiac outflow obstruction. 


Investigations

• ECG - Remember, ECG is a snapshot and some patients with an underlying arrhythmia may have normal ECG
• Selection of other laboratory tests should be guided by clinical suspicion. Blood tests are required as indicated by history. Consider performing a serum alcohol level, a urine drug screen and a beta hCG in adolescents. 
• ECHO - Done for those with known cardiac disease, abnormal heart sounds, abnormal cardiac murmurs, evidence of cardiac chamber enlargement, or repolarization abnormalities on ECG, or other features that suggest myocardial dysfunction.
• EEG -  Low diagnostic yield and not needed routinely.

A detailed history, physical exam, and ECG have a 96% sensitivity for detecting cardiac syncope.

Things to look for in ECG:

• Brady and Tachyarrythmias (AV Blocks, SVT, AF, VT)
• Brugada (IRBBB, STE V1-V3)
• QTc (Long and Short)
• WPW (triad - Wide QRS, Short PR, Delta wave)
• HOCM (High LV Voltage, dagger like q waves, TWI)
• ARVD (epsilon wave)
• Chamber Enlargement 
• Septal Defects (Crochetage Pattern for OS ASD)

Treatment

Treatment is targeted to specifically identified causes of the syncopal event; 80% of the time, this will be neurocardiogenic syncope, and treatment for these patients includes reassurance and oral fluids. Children with a normal ECG, full recovery and no cardiac risk factors or exercise-induced symptoms may be safely evaluated as outpatients.

Take Home:

• A detailed history, physical exam, and ECG have a 96% sensitivity for detecting cardiac syncope.
• There are no routine blood tests - request bloods based on history and physical.
• Know what to look for in the ECG in patients presneting with syncope.

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic

GABHS Pharyngitis - Strep throat

Group A β-hemolytic Streptococcus pharyngitis is the most commonly occurring form of acute bacterial pharyngitis primarily affecting children age 5-15 years old. It is typically a self-limited disease where symptoms diminish markedly at days 3 and 4 after symptom onset, and antibiotics only decrease the duration of symptoms by approximately 16 hours. Use of antibiotics for everyone with strep throat is controversial with but most physicians are not comfortable withholding antibiotics. Read this post on REBEL EM questioning the use Abx in strep throat. 

Symptoms of acute pharyngitis:

• Sore throat, cough, hoarseness, coryza
• Odynophagia
• Fever
• Headache, abdominal pain, nausea and vomiting, diarrhea
• Arthralgias, myalgias,lethargy

Symptoms suggestive of viral infection:

• Conjunctivitis, Coryza, Cough
• Diarrhea, Hoarseness, Viral Exanthem

Physical examination findings:

• Tonsillopharyngeal erythema and/or exudates
• Soft palate petechiae, uvulitis
• Anterior cervical lymphadenitis

It is difficult to distinguish between viral and bacterial causes based on physical examination alone, and tonsillar exudate does not imply bacterial etiology. Bacterial etiology is often overdiagnosed and unnecessary antibiotic treatment is given. 

Several clinical prediction rules have been created to identify cases of GABHS pharyngitis, and a commonly used rule is FeverPAIN score (recommended by NICE guidelines). 

Diagnosis

Performing diagnostic testing depends on local protocols but it is generally done by obtaining a swab from the throat and doing rapid antigen detection test (RADT) and/or culture because the clinical features alone do not reliably discriminate between GAS and viral pharyngitis. Routine use of backup throat cultures for those with a negative RADT is not necessary for adults. Anti-streptococcal antibody titers are not recommended in the routine diagnosis of acute pharyngitis as they reflect past but not current events. 

• Gold standard for diagnosis - Bacterial culture (sensitivity of 90% to 95%)
• Rapid antigen detection (highly specific, sensitivity 80% to 90%) 
• 
  

Current American guidelines recommend confirmatory throat culture for all patients with a negative antigen test. The antibiotic treatment of GABHS pharyngitis shortens the duration of illness, prevents transmission, prevent suppurative complications (acute otitis media, acute sinusitis, and peritonsillar abscess), and prevent systemic illness such as rheumatic fever, rheumatic heart disease, and post-streptococcal glomerulonephritis. Antibiotics for the treatment of GABHS pharyngitis should be reserved for those patients with a positive antigen test or culture, or those meeting clinical criteria for diagnosis. 

Here is a summary of NICE guidelines:

Decision Rules 
FeverPAIN score 
Centor Criteria 



Treatment

• Symptom relief with NSAIDs
• Local Anethetics sprays 
• Antibiotics (Her is another perspective on Abx use in Strep throat)
• Steroids - Emerging evidence to achieve better symptoms relief 

Antibiotic treatment can be delayed safely for a few days after symptom onset and still prevent major nonsuppurative sequelae. This provides us time to get confirmatory cultures. Also, there is no definitive evidence that antibiotic use can prevent acute glomerulonephritis. 

Penicillin remains the treatment of choice. A course of 10 days of oral therapy with twice-a-day dosing is recommended for complete pharyngeal eradication; similar efficacy is achieved with once-daily dosing of amoxicillin for 10 days. Clarithromycin and first-generation cephalosporins are alternatives in penicillin-allergic patients. Clindamycin may be required for macrolide-resistant GABHS in the penicillin-allergic patient. 


Take Home:

• Know your local protocols about diagnostic testing and indications for antibiotics. 
• Strep throat is typically a self-limited disease where symptoms diminish markedly at days 3 and 4
• There is no definitive evidence that antibiotic use can prevent acute glomerulonephritis
• It is difficult to distinguish between viral and bacterial causes based on physical examination alone.

References and Further Reading:

1. Shaikh N, Swaminathan N, Hooper EG: Accuracy and precision of the signs and symp- toms of streptococcal pharyngitis in children: a systematic review. J Pediatr 160: 487, 2012. [PMID: 22048053]
2. Bisno AL: Acute pharyngitis. N Engl J Med 344: 205, 2001. [PMID: 11172144]
3. Centor RM, Witherspoon JM, Dalton HP, et al: The diagnosis of strep throat in adults in the emergency room. Med Decis Making 1: 239, 1981. [PMID: 6763125]
4. Wong DM, Blumberg DA, Lowe LG: Guidelines for the use of antibiotics in acute upper respiratory tract infections. Am Fam Physician 74: 956, 2006. [PMID: 17002029]
5. Shulman ST, Bisno AL, Clegg HW, et al: Clinical practice guideline for the diagnosis and management of group A streptococcal pharyngitis: 2012 update by the Infectious Diseases Society of America. Clin Infect Dis 55: e91, 2012. [PMID: 23091044]
6. https://www.nice.org.uk/guidance/ng84/documents/draft-guidance
7. https://academic.oup.com/cid/article/55/10/e86/321183
8. https://www.nice.org.uk/guidance/ng84/chapter/summary-of-the-evidence#corticosteroids
9. http://www.idsociety.org/uploadedFiles/IDSA/Guidelines-Patient_Care/PDF_Library/Strep.pdf

Posted by:

              

     Lakshay Chanana

     

     Speciality Doctor

     Northwick Park Hospital

     Department of Emergency Medicine

     England

     @EMDidactic