Secrets – Pediatric: Emergency Medicine

Secrets – Pediatric: Emergency Medicine

BIOTERRORISM
1. Why are children more vulnerable to biologic agents than adults?
• Anatomic and physiologic differences: Thinner dermis, increased surface area-to-volume ratio, smaller relative blood volume, higher minute ventilation
• Developmental considerations: Inability to flee dangerous situations, possible increased risk for post-traumatic stress disorder (PTSD)
• Some vaccines not licensed for children: Anthrax (18 to 65 years), plague (18 to 61 years)
• Vaccines more dangerous in children: Smallpox, yellow fever
• Antibiotics less familiar to pediatricians: Tetracyclines, fluoroquinolones

Cieslak TJ, Henretig FM: Bioterrorism, Pediatr Ann 32:145–165, 2003. Centers for Disease Control and Prevention Emergency Preparedness Response: http://www.bt.cdc.gov. Accessed 11-21-14.

2. What are the three routes of transmission of anthrax?
• Inhalation: Most feared; can lead to multiorgan hemorrhagic necrosis
• Cutaneous: Inoculated through wound, causing a black, painless ulcer
• Ingestion: May cause gastrointestinal or upper respiratory symptoms
Bacillus anthracis, which is a spore-forming gram-positive rod, can survive for extended periods before entering the body, when it will germinate and proliferate (Fig. 5-1).

Figure 5-1. Cutaneous anthrax in a child. (From Schachner LA, Hansen RC, editors: Pediatric Dermatology, ed 3. Edinburgh, 2003, Mosby,
p 1033.)

3. How are the lesions of smallpox distinguished from varicella (chickenpox)?
• Smallpox lesions predominate on the face and extremities (centrifugal), whereas VARICELLA lesions are typically heaviest on the trunk (centripetal).
• Rash of smallpox progresses in similar stages (macules, papules, vesicles, crusting), whereas
VARICELLA is seen with multiple crops in differing stages.
• Smallpox rash develops more slowly than VARICELLA rash.
4. How can the presenting symptoms of bubonic plague be differentiated from those of plague resulting from bioterrorism? Bubonic plague—of “black death” fame—resulted from the bite of fleas, which led to large tender regional adenopathy (the “bubo”) with subsequent hematogenous dissemination, multiorgan involvement, and septicemia. In bioterrorism, the organism Yersinia pestis could be aerosolized, and inhalation would result
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in presentations more typical of pneumonic plague, with fever, chills, tachypnea, cough, and bloody sputum; lymphadenitis would likely be a later finding.

Dennis DT, Chow CC: Plague, Pediatr Infect Dis J 23:69–71, 2004.

5. Why should families living near nuclear power plants keep potassium iodide (KI) in their medicine cabinets?
The American Academy of Pediatrics recommends that families living within 10 miles of a nuclear power plant (or 50 miles in densely populated areas, where evacuations may be more difficult) have KI on hand in the event of a nuclear radiation catastrophe. KI will inhibit the uptake of radioactive iodine (131I) into the thyroid gland. Children are more susceptible than adults to the subsequent development of thyroid cancer if exposed. If KI is administered within 1 hour, 90% of 131I is blocked, but after 12 hours, there is little effect.

Committee on Environmental Health, American Academy of Pediatrics: Radiation disasters and children, Pediatrics
111:1455–1466, 2003.

6. Why are children particularly vulnerable to terrorism in the form of explosive and blast attacks?
• Smaller mass results in greater force per unit of body surface from energy released by explosion.
• Children are more susceptible to fractures as a result of incompletely calcified growth plates.
• The chest wall has greater pliability in children, resulting in greater chance of cardiac and pulmonary injury from blast explosives.

Garth RJN: Blast injury of the ear: an overview and guide to management, Injury 26:363–366, 1995.

7. What categories of agents should be considered in the event of a chemical weapons attack?
• Nerve: Nerve agents are similar to organophosphate insecticides and include cholinesterase inhibitors, such as Sarin, Soman, and VX. Nerve agents inhibit the action of acetylcholinesterase at cholinergic neural synapses, where acetylcholine then accumulates. These agents are generally colorless, odorless, tasteless, and nonirritating to the skin. Nerve agent vapors are denser than air and tend to accumulate in low-lying areas, putting children at a higher risk than adults for exposure. The agents used in terrorist attacks are inhaled and absorbed through skin and mucous membranes.
• Asphyxiants: Asphyxiants are toxic compounds that inhibit cytochrome oxidase, causing cellular anoxia and lactic acidosis (high anion gap). Hydrogen cyanide, the most commonly known toxicant in this class, is a colorless liquid or gas that smells like bitter almonds. Exposure to hydrogen cyanide produces rapid onset of tachypnea, tachycardia, and flushed skin, followed by nausea, vomiting, confusion, weakness, trembling, seizures, and death.
• Choking and pulmonary agents: Choking agents include chlorine and phosgene. When inhaled, these agents produce massive mucosal irritation and edema, as well as significant damage to lung parenchyma.
• Blistering and vesicant agents: Blistering agents include sulfur mustard and lewisite. Sulfur mustard is an alkylating agent that is highly toxic to rapidly reproducing and poorly differentiated cells; skin, pulmonary parenchyma, and bone marrow are frequently damaged. Lewisite is an arsenical compound that affects skin and eyes immediately on exposure.
8. What should be the practitioner’s initial management when a chemical weapons event occurs?
The single most important first step for treating all chemical exposures is the initial decontamination strategy. Immediate removal of patient clothing can eliminate about 90% of contaminants.

CHILD ABUSE: PHYSICAL AND SEXUAL
9. What are important historical indicators of possible child abuse?
• Multiple previous hospital visits for injuries
• History of untreated injuries
• Cause of trauma not known or inappropriate for age or activity

• Delay in seeking medical attention
• History incompatible with injury
• Parents unconcerned about injury or more concerned about unrelated minor problem (e.g., cold, headache)
• History of abused siblings
• Changing or inconsistent stories to explain injury

Sirotnak AP, Grigsby T, Krugman RD: Physical abuse of children, Pediatr REV 25:264–276, 2004. Kottmeier P: The battered child, Pediatr Ann 16:343–351, 1987.

10. What is the most common cause of severe closed head trauma in infants younger than 1 year?
ABUSIVE head trauma. This is the terminology adopted by the American Academy of Pediatrics to replace the term shaken baby syndrome. It describes inflicted injury in infants and young children that
results either from an impact to the head or violent shaking of the head, or a combination of both mechanisms. The term shaken baby syndrome was changed because it implied a knowledge on the part of the treating clinician of the mechanism of injury that was most often not known. Abusive head trauma is most common in infants <1 year of age and, compared with accidental head injury, has a much greater mortality rate. Male infants, and those from lower socioeconomic groups, tend to be at highest risk. Abusive head trauma manifests as subdural hematomas, subarachnoid hemorrhages, and cerebral infarcts. The diagnosis is suggested by the lack of a corroborating mechanism of injury in the face of a symptomatic child or, rarely, a confession by the perpetrator. In many cases, physical examination reveals retinal hemorrhages (Fig. 5-2); other signs of trauma are usually lacking. Diagnosis is confirmed by computed tomography (CT) or magnetic resonance imaging (MRI). If a lumbar puncture is performed, the fluid may be bloody or xanthochromic. The prognosis is grim for an infant who is in coma from this abuse: 50% die, and nearly half of the survivors have significant neurologic sequelae.

Niederkrotenthaler T, Xu L, Parks SE, et al: Descriptive factors of abusive head trauma in young children: United States,
Child Abuse Legl 37:446–455, 2013.
Christian CW, Block R, Committee on Child Abuse and Neglect: Abusive head trauma in infants and children, Pediatrics
123:1409–1411, 2009.

Figure 5-2. Retinal hemorrhages of victim of abusive head trauma. (From Zitelli BJ, DAVIS HW: Atlas of Pediatric Physical Diagnosis, ed 4.
St. Louis, 2002, Mosby, p 181.)

11. Why is the diagnosis of abusive head trauma often overlooked? When an infant is unconscious with respiratory distress, apnea, and/or seizures, the diagnosis of abusive head trauma should be considered. However, depending on the degree of impact or shaking and the degree of resulting damage, the symptoms can be mild and nonspecific and may mimic symptoms of

a viral illness, feeding disorder or dysfunction, or even colic. Victims may have a history of poor feeding, vomiting, lethargy, and/or irritability that may have gone on for days or weeks. Early identification of abusive injuries is critical because of the risk of increased mortality with each recurrent abusive event.

Schwartz, KA, Preer G, Mckeag H, et al: Child maltreatment: a review of key literature in 2013, Curr Opin Pediatr
26:396–404, 2014.
Jaspan T: Current controversies in the interpretation of nonaccidental head injury, Pediatr Radiol 38:S378–S387, 2008.

12. What diagnostic tests may be contributory if abusive head trauma is suspected?
• Head CT: Good for demonstrating subarachnoid and large extra-axial hemorrhages and mass effect; may be falsely negative, especially early in the presentation
• MRI: Good for diagnosing subdural hemorrhages and intraparenchymal lesions; may miss subarachnoid blood and fractures
• Spinal tap: May yield bloody cerebrospinal fluid
• Skeletal survey: May be normal or may reveal acute or healed rib or other fractures, which are suggestive of abuse
• Complete blood count: May be normal or may show mild to moderate anemia
• Prothrombin time and partial thromboplastin time: May show mild to moderate abnormalities or reveal frank disseminated intravascular coagulation (DIC)
• Amylase: May show an increase, signifying possible pancreatic damage
• Liver function tests: Abnormalities may signify occult liver injury

American Academy of Pediatrics, Section on Radiology: Diagnostic imaging of child abuse, Pediatrics 123:1430–1435, 2009.

13. What physical examination findings are indicators of possible child abuse?
• Burns, especially cigarette or immersion burns on the buttocks or perineum or burns in a stocking- and-glove distribution
• Genital trauma or sexually transmitted infection (STI) in a prepubertal child
• Signs of excessive corporal punishment (welts, belt or cord marks, bites)
• Frenulum lacerations in young infants or tongue bruising (associated with forced feeding)
• Multiple bruises in various stages of resolution
• Bruises in a premobile infant
• Neurologic injury associated with retinal or scleral hemorrhages
• Fractures suggestive of abuse (e.g., skull fractures in infants, metaphyseal fractures, posterior rib fractures, fractures in premobile infants, scapular fractures in infants beyond the immediate newborn period)

Sirotnak AP, Grigsby T, Krugman RD: Physical abuse of children, Pediatr REV 25:264–276, 2004. Kottmeier P: The battered child, Pediatr Ann 16:343–351, 1987.

14. If retinal hemorrhages are noted in a child with seizures, how likely are the seizures to have caused the hemorrhages? In theory, any seizure might cause retinal hemorrhages through a sudden rise in retinal venous pressure in conjunction with increased central venous and intrathoracic pressure. However, a prospective study of children with seizures who had ophthalmologic evaluation found no evidence of an association of seizures and retinal hemorrhages. Combining their data with some previous studies, the authors determined a prevalence of retinal hemorrhages with a seizure of only about 3 per 10,000—an extremely small likelihood. If retinal hemorrhages are found in a child with seizures, the possibility of nonaccidental injury must be explored.

Curcoy AI, Trenchs V, Morales M, et al: Do retinal haemorrhages occur in infants with convulsions? Arch Dis Child
94:873–875, 2009.

15. In a suspected victim of child abuse, is an ophthalmology exam looking for retinal hemorrhages routinely indicated as part of the medical evaluation? The answer used to be yes. In the past, all suspected child abuse victims of any sort were subjected to a screening eye exam for detection of retinal hemorrhages. However, recent research has convincingly

demonstrated that in the absence of positive neuroimaging, an eye exam will not reveal clinically significant retinal hemorrhages and is not necessary.

Greiner MV, Berger RP, Thackeray JD, et al: Dedicated retinal examination in children evaluated for physical abuse without radiographically identified traumatic brain injury, J Pediatr 163:527–531, 2013.

16. When should child abuse be considered in the event of an unexplained death of a child?
Always. Sudden infant death syndrome (SIDS) should be a diagnosis of exclusion in any unexplained death. Deaths as a result of SIDS usually occur during the first year of life, most commonly (90%) in children <7 months old. All children who die suddenly of unclear causes should have a complete physical examination that looks for signs of external trauma (e.g., bruises, injury to the genitalia).

17. Which conditions with ecchymoses (bruising) can be mistaken for child abuse?
• Mongolian spots (dermal melanosis) are commonly mistaken for bruises, especially when they occur elsewhere than the classic lumbosacral area; unlike bruises, they do not fade with time (Fig. 5-3).
• Coagulation disorders include hemophilia or von Willebrand disease. In 20% of cases of hemophilia, there is no family history of disease; bruising may be noted in unusual places in response to minor trauma.
• Folk medicine such as the Southeast Asian practices of spoon rubbing (quat sha) or coin rubbing (cao gio) can produce ecchymoses; the practice of cupping (the inversion of a heated cup on the back) produces circular ecchymoses.
• Moxibustion is the Southeast Asian practice of burning an herbal substance on the child’s abdomen to cure disease.
• Clothing dyes, especially from jeans, sometimes mimic bruising; they are easily removed with topical alcohol.
• Vasculitis, particularly Henoch-Sch€onlein purpura with a purpuric rash most commonly on the buttocks and lower extremities or idiopathic thrombocytopenic purpura (ITP), may be mistaken for signs of child abuse.
• Vitamin K deficiency

Kaczor K, Pierce MC, et al: Bruising and physical child abuse, Clin Pediatr Emerg Med 7:153–160, 2006.

Figure 5-3. Mongolian spots (dermal melanosis) on an infant. (From Jenny C, editor: Child Abuse and Neglect, Philadelphia, 2011, ELSEVIER Saunders, p 253.)

18. How are fractures dated radiographically in children?
After a fracture, the following will be seen:
• 1 to 7 days: Soft tissue swelling; fat and fascial planes blurred; sharp fracture line
• 7 to 14 days: Periosteal new bone formation as soft callus forms; blurring of fracture line; occurs earlier for infants, later for older children
• 14 to 21 days: More clearly defined (i.e., hard) callus forming as periosteal bone converts to lamellar bone
• 21 to 42 days: Peak of hard callus formation
• ≥60 days: Remodeling of bone begins with reshaping of the deformity (up to 1 to 2 years)
If the timing of an injury does not correlate with the dating of a fracture or if fractures at multiple stages of healing are present, child abuse should be suspected.
19. What fractures are suggestive of child abuse? All fractures can be the result of child abuse, and a careful history will guide the clinician in the degree of suspicion indicated in each case. In infants and toddlers, physical abuse is the cause of up to 20% of fractures. This is an age group in which suspicion should be high. Some fractures have been shown to have a high specificity for abuse, and these are rib fractures in infants, particularly posteriomedially; classic metaphyseal lesions of long bones; and fractures of the scapula, spinous process, and sternum. Metaphyseal fractures (Fig. 5-4) require shearing forces not usually produced in accidental trauma, with an increased likelihood of mechanisms that involve shaking with limbs flailing, twisting, and jerking. The presence of multiple fractures, fractures of different ages and/or stages of healing, and complex skull fractures also have a good degree of specificity for abuse.

Flaherty EG, Perez-Rossello JM: Evaluating children with fractures for child physical abuse, Pediatrics 133: e477–e489, 2014.
Pierce MC, Bertocci G: Fractures resulting from inflicted trauma: assessing injury and history compatibility, Clin Pediatr Emerg Med 7:143–148, 2006.

Figure 5-4. Radiograph of classic metaphyseal (arrow) lesions. (From Jenny C, editor: Child Abuse and Neglect, Philadelphia, 2011, ELSEVIER Saunders, p 285.)

20. How certain can a clinician be in attributing a femur fracture in a nonambulatory child to nonaccidental trauma?
Femoral fractures in the nonambulatory child are most often the result of nonaccidental trauma. However, there are exceptions to this “rule.” Certain femur fractures in young children may be accidental:
• A short fall to the knee may produce a torus or impacted transverse fracture of the distal femoral metaphysis.
• Children playing in a stationary activity center, like an Exersaucer, may sustain an oblique distal femur metaphyseal fracture.
• Falls down a stairway in a nonambulatory child can sometimes cause one leg to become twisted underneath the child resulting in a spiral femoral fracture.

Haney SB, Boos SC, Kutz TJ, et al: Transverse fracture of the distal femoral metadiaphysis: a plausible accidental mechanism, Pediatr Emerg Care 25:841–844, 2009.
Pierce MC, Bertocci GE, Janosky JE, et al: Femur fractures resulting from stair falls among children: an injury plausibility model, Pediatrics 115:1712–1722, 2005.

21. What is the purpose of the skeletal survey?
Skeletal injuries, particularly multiple healed lesions, are strong indicators of a pattern of abuse. The skeletal survey is a radiological evaluation of multiple bones in the body to:
1. reveal fractures of additional bones (new or healing) other than the fractured bones already known to the clinician; and
2. reveal fractures (new or healing) in a child suspected of abuse manifesting in ways other than fractures.

22. What constitutes the skeletal survey?
The skeletal survey is a multiple-imaging series that includes x-ray views of the following:
• Appendicular skeleton: Humeri, forearms, hands, femurs, lower legs, and feet
• Axial skeleton: Thorax, pelvis (including mid- and lower lumbar spine), lumbar spine, cervical spine, and skull
The series can include anywhere between 19 and 30 x-rays. “Body grams” (studies that encompass the entire child in one or two exposures) are not thought to be of sufficient sensitivity to be useful.

American Academy of Pediatrics, Section on Radiology: Diagnostic imaging of child abuse, Pediatrics 123: 1430–1431, 2009.

23. Up to what age should a skeletal survey be ordered?
If physical abuse is suspected, the American Academy of Pediatrics recommends a mandatory study in children up to the age of 2 years. The yield diminishes after that age and is of little value after the age of 5 years.

American Academy of Pediatrics, Section on Radiology: Diagnostic imaging of child abuse, Pediatrics 123: 1432, 2009.

24. What is the value of a follow-up skeletal survey?
Both the American Academy of Pediatrics and the American College of Radiology recommend follow-up skeletal surveys about 2 weeks after the initial study if the first was abnormal or equivocal or when abuse is suspected on clinical grounds despite a normal first study. The follow-up skeletal survey can demonstrate a previously-missed occult fracture by the presence of new callus formation. The yield can be substantial with studies demonstrating new findings ranging from 14% to 61%. Because
of the additional radiation, research is also addressing the applicability of more limited views on the follow-up study.

Hansen KK, Keeshin BR, et al: Sensitivity of the limited view follow-up skeletal survey, Pediatrics 134: 242–248, 2014.

25. In addition to child abuse, what conditions must you consider as a cause of multiple unexplained long bone fractures in a young child?
• Osteogenesis imperfecta (OI) is a rare congenital disorder that presents with bone fragility. In addition to frequent fractures, patients with this disorder often present with the following:
• Blue sclera
• Ligamentous laxity
• Osteopenia
• Wormian skull bones
• Dentinogenesis imperfecta
• Family history of OI (although not always because new cases can result from de novo mutations)
• Hearing loss
• Vitamin D deficiency rickets
• Scurvy
• Copper deficiency
26. When are burn injuries suspicious for child abuse? Burn injuries account for about 5% of cases of physical abuse. As with other injuries, the description of the incident causing the burn should be consistent with the child’s development and the extent and degree of the burn observed. The following types are suspicious for abuse:
• Immersion burns: Sharply demarcated lines on the hands and feet (stocking-and-glove distribution), buttocks, and perineum, with a uniform depth of burn; the immersion of a child in a hot bath is a classic example
• Geographic burns: Burns, usually of second or third degree, in a distinct pattern, such as circular cigarette burns or steam iron burns
• Splash burns: Pattern with droplet marks projecting away from the most involved area; splash marks on the back of the body usually require another person and may or may not be accidental
27. How do you recognize child abuse in a medical setting?
In this form of child abuse, also called Munchausen syndrome or pediatric condition falsification,
adult caregivers inflict illness on a child or falsify symptoms to obtain medical care for a child. Features include the following:
• Recurrent episodes of a confusing medical picture
• Multiple diagnostic evaluations at different medical centers (“doctor shopping”)
• Unsupportive marital relationship, often with maternal isolation
• Compliant, cooperative, and overinvolved mother
• Higher level of parental medical knowledge
• Parental history of extensive medical treatment or illness
• Conditions resolve with surveillance of the child in the hospital
• Findings correlate with the presence of the parent

Stirling J: Beyond Munchausen syndrome by proxy: identification and treatment of child abuse in a medical setting,
Pediatrics 119:1026–1030, 2007.

28. How often is sexual abuse committed by an individual known previously by the child or adolescent?
Between 75% and 80% of the time. Relatives are the perpetrators in about one third of cases.
29. In the case of suspected prepubertal sexual abuse, how critical is it to perform the physical exam immediately on presentation of the child to a medical facility?
If no exchange of bodily fluids has occurred, and the child is not presenting with a medical emergency, such as vaginal bleeding, it is not necessary to perform a medical exam immediately in the office or emergency department (ED) setting. In fact, it is preferential to refer the child to a setting staffed by medical personnel familiar with the sexual abuse exam, such as a pediatric emergency department or a child advocacy center. If exchange of bodily fluids has occurred, then the timing of the exam is more critical. Guidelines vary from state to state with recommendations that forensic evidence be collected from 24 hours to 96 hours after an assault.

30. After the documentation of history and a careful physical examination, what evidence should be collected in cases of suspected sexual abuse in a prepubertal female? Because sexually transmitted infections are not common in prepubertal children evaluated for abuse, culturing all sites (vaginal, rectal, and oral) for all organisms is not recommended if the child is not symptomatic. Each case should be treated individually. However, here are some considerations:
• Whether the child was penetrated, either vaginally or anally
• Whether the abuser was a stranger
• Whether the abuser is known to have an STI or be at risk
• Whether the child has a sibling or other relative in the household with an STI
• Whether the child has signs or symptoms of an STI
• Whether the child has already been diagnosed with a previous STI If the decision is made to collect specimens from a prepubertal child, the AAP recommends the use
of a nucleic acid amplification test (NAAT) for detection of infection with Chlamydia trachomatis and Neisseria gonorrhoeae. Culture-based tests for these organisms are highly insensitive. However, it should be noted that the Food and Drug Administration (FDA) has not approved the use of the NAAT for cultures of the rectum and throat in pediatric patients.

Jenny C, Crawford-Jakubiak JE: The evaluation of children in the primary care setting when sexual abuse is suspected,
Pediatrics 132:e558–e567, 2013.

31. After the documentation of history and a careful physical examination, what evidence should be collected in cases of suspected sexual abuse in a postpubertal female?
• Pregnancy test, if postmenarchal
• Evidence of sexual contact, including two to three swabbed specimens from each area of assault for the following substances: sperm (motile and nonmotile), acid phosphatase (secreted by the prostate; component of seminal plasma), P30 (prostate glycoprotein present in seminal fluid), blood group antigens
• NAAT for STIs from all three sites
• Evidence to document perpetrator: foreign material on clothing, suspected nonpatient hairs; DNA testing (controversial)

Jenny C, Crawford-Jakubiak JE: The evaluation of children in the primary care setting when sexual abuse is suspected,
Pediatrics 132;e558-e567, 2013. American Academy of Pediatrics, Committee on Child Abuse and Neglect: Guidelines for the evaluation of sexual abuse in children, Pediatrics 116:506–512, 2005.

32. After the initial ED evaluation for sexual assault, what kind of follow-up care should the ED physician offer?
• Human immunodeficiency virus (HIV) follow-up counseling with infectious disease or HIV specialist in 3 to 5 days
• Follow-up gynecologic examination at 1 to 2 weeks
• Repeat serologic tests for syphilis and HIV in 6 weeks, 3 months, and 6 months
• Psychiatric counseling
33. If a child who is not sexually active is diagnosed with an infection caused by an STI-associated organism, how likely is sexual abuse the reason for acquisition?
See Table 5-1.

Table 5-1. Likelihood of Sexual Abuse According to Organism
ORGANISM LIKELIHOOD OF SEXUAL ABUSE
Neisseria gonorrhoeae Diagnostic
Treponema pallidum (syphilis) Diagnostic
Chlamydia trachomatis Diagnostic
Human immunodeficiency virus Diagnostic

Table 5-1. Likelihood of Sexual Abuse According to Organism (Continued )
ORGANISM LIKELIHOOD OF SEXUAL ABUSE
Trichomonas VAGINALIS Highly suspicious
Condyloma acuminata Suspicious
Herpes (genital location) Suspicious
Bacterial vaginosis Inconclusive
Adapted from American Academy of Pediatrics: Sexually transmitted diseases. In Pickering LK, editor: 2006 Red Book, ed 27. Elk GROVE Village, IL, 2006, American Academy of Pediatrics, p 172.

34. Is the size of the hymenal opening an important finding in the diagnosis of sexual abuse?
The hymenal opening is measured with a child in the supine, frog-leg position, and various studies have attempted to determine a size that most likely correlates with sexual abuse. The upper limit of normal had ranged from 4 to 8 mm, but variations in technique, positioning, and relative relaxation of the patient have rendered such measurements generally unhelpful and nondiagnostic. A more important part of the examination is inspection of the posterior hymen and surrounding tissues. Typically, a posterior rim of hymen measuring at least 1 mm is present unless there has been trauma. Complete transaction of the hymen leaves a permanent gap or defect. A full-thickness transaction through the posterior hymen (best visualized in the knee-chest position) is thought to be reliable evidence of trauma.
Other variations of hymenal shape or size must be interpreted with caution because there is considerable overlap among abused and nonabused girls.

Berkoff MC, Zolotor AJ, Makoroff KL, et al: Has this prepubertal girl been sexually abused? JAMA
23:2779–2792, 2008.
Pillai M: Genital findings in prepubertal girls: what can be concluded from an examination? J Pediatr Adolesc Gynecol
21:177–185, 2008.

35. What is the most common finding of the physical examination of a child who has been sexually abused?
A normal physical examination is the most common physical finding, which is why, in the absence of vaginal bleeding or other medical emergency, the physical exam should be deferred to an experienced medical examiner in a pediatric ED or a child advocacy center. It is crucial to know that a normal examination does not rule out sexual abuse.
36. What are the date-rape drugs?
Date-rape drugs are substances that render a patient incapable of saying “no” or asserting herself or himself, which makes it easier for a perpetrator to commit rape. The term typically applies to three drugs—flunitrazepam (Rohypnol), γ-hydroxybutyrate (GHB), and ketamine hydrochloride—which go by a variety of street names. The effects of these drugs, including somnolence, muscle relaxation, and profound sedation and amnesia, are enhanced by the concurrent use of alcohol.

Kaufman M: Care of the adolescent sexual assault victim, Pediatrics 122:462–470, 2008.

37. How can you tell whether a patient has been given a date-rape drug?
Most of these drugs can be detected in blood and/or urine. However, because they are metabolized very quickly, it is important to screen early in your evaluation of the patient. For example, Rohypnol can be detected in blood for 24 hours and in urine up to 48 hours, GHB in urine only for up to 12 hours after ingestion, and ketamine in urine for up to 72 hours. None of these drugs is included in routine drug screen panels.

Kaufman M: Care of the adolescent sexual assault victim, Pediatrics 122:462–470, 2008.

KEY POINTS: FRACTURES OF ABUSE
1. Any fracture can be the result of nonaccidental trauma.
2. Critical in assessment: history, age of patient, developmental level of the patient, family history
3. Fractures with higher likelihood of abuse: rib, scapula, spinous process, sternum, long bone with metaphyseal lesions
4. Suspicious fractures: <18 months of age with humeral shaft fracture, complex or bilateral skull fractures, femoral fracture in nonambulatory child (without correlating history)
5. Skeletal surveys are indicated for suspected nonaccidental trauma in children <2 years of age.

KEY POINTS: RETINAL HEMORRHAGES
1. May be the only sign in an infant of a nonaccidental shaking injury
2. Almost never caused by seizures alone
3. Should always be assessed in an infant whose presenting symptoms include excessive irritability, lethargy, sepsislike appearance, seizures, or coma
4. Should always be confirmed by an ophthalmologist
5. If found, should be followed by a skeletal series and cranial neuroimaging (computed tomography scanning and/or magnetic resonance imaging)

KEY POINTS: SEXUAL ABUSE
1. The most common physical finding is a normal examination.
2. The perpetrator is known to the victim in 75% to 80% of cases.
3. Infections that are diagnostic of abuse are gonorrhea, syphilis, chlamydia, and HIV.
4. For a prepubertal victim of sexual assault, NAAT is the preferred test for gonorrhea and chlamydia because a culture is too insensitive.
5. Reasons for immediate medical examination include ongoing bleeding or evidence of acute injury.
6. Use of accepted or standardized protocols is important during the evaluative process.
HIV, Human immunodeficiency virus; NAAT, nucleic acid amplification test.

ENVIRONMENTAL INJURY
38. How do fresh- and salt-water drownings differ?
Fresh water injures the lung primarily by disrupting surfactant, thereby leading to alveolar collapse. Damage to the alveolar membranes leads to the transudation of fluid into the air spaces and pulmonary edema. Salt water pulls fluid into the air spaces directly by creating a strong osmotic gradient, and the accumulated water washes away surfactant, thereby leading to alveolar collapse. Both types result in abnormal surfactant function and increased capillary endothelial permeability. Patients develop ventilation-perfusion mismatch and hypoxemia, which may require aggressive mechanical support.
Ultimately, management for either fresh- or salt-water drowning is the same.

Meyer RJ, Theodorou AA, Berg RA: Childhood drowning, Pediatr REV 27:163–169, 2006.

39. How is the duration of submersion predictive of outcomes in drownings?
Risk of death or severe neurologic impairment after hospital discharge increases with duration of submersion as follows:

0 to 5 minutes: 10%
6 to 10 minutes: 56%
11 to 25 minutes: 88%
>25 minutes: nearly 100%

Signs of brain-stem injury are also predictive of death or severe neurologic sequelae.

Szpilman D, Bierens JJLM, Handley AJ, et al: Drowning, N Engl J Med 366:2102–2110, 2012.

40. What cardiovascular changes occur as body temperature falls?
• 31 °C to 32 °C: Elevated heart rate, cardiac output, and blood pressure; peripheral vasoconstriction and increased central vascular volume; normal electrocardiogram (ECG)
• 28 °C to 31 °C: Diminished heart rate, cardiac output, and blood pressure; ECG irregularities include premature ventricular contractions (PVCs), supraventricular dysrhythmias, atrial fibrillation, and
T-wave inversion
• <28 °C: Severe myocardial irritability; ventricular fibrillation, usually refractory to electrical defibrillation; often absent pulse or blood pressure; J waves on ECG
41. What are the physiologic consequences of externally warming a severely hypothermic patient too rapidly?
• Core temperature “after-drop”: The body temperature drops because external rewarming causes peripheral vasodilation and the return of cold venous blood to the core.
• Hypotension: Peripheral vasodilation increases total vascular space, thereby causing a drop in blood pressure.
• Acidosis: Lactic acid returns from the periphery, thereby resulting in rewarming acidosis.
• Dysrhythmias: Rewarming alters acid-base and electrolyte status in the setting of an irritable myocardium.
42. What are acceptable rewarming methods for the hypothermic child?
For patients with mild hypothermia (32 °C to 35 °C), passive rewarming by removing cold clothing and placing the patient in a warm, dry environment with blankets is generally sufficient. Active external rewarming involves the use of heating blankets, hot-water bottles, and overhead warmers and can also be used for patients with acute hypothermia in the 32 °C to 35 °C range. Active external rewarming should not be used for chronic hypothermia (>24 hours). More aggressive core rewarming techniques should be considered for patients with temperatures lower than 32 °C. These techniques include gastric or colonic irrigation with warm fluids, peritoneal dialysis, pleural lavage, and extracorporeal blood rewarming with partial bypass. Intravenous and other fluids should be heated to 43 °C. Patients should be given warmed, humidified oxygen by facemask or endotracheal tube.

Brown DJA, Brugger H, Boyd J, Paal P: Accidental hypothermia, N Engl J Med 367:1930–1938, 2012.

43. What organ systems are affected in patients suffering from heat stroke?
Heat stroke is a medical emergency of multisystem dysfunction that includes a very high body temperature (usually >41.5 °C). The systems that are affected include the following:
• Central nervous system (CNS): Confusion, seizures, and loss of consciousness
• Cardiovascular: Hypotension as a result of volume depletion, peripheral vasodilation, and myocardial dysfunction
• Renal: Acute tubular necrosis and renal failure, with marked electrolyte abnormalities
• Hepatocellular: Injury and dysfunction
• Heme: Abnormal hemostasis, often with signs of DIC
• Muscle: Rhabdomyolysis

Jardine DS: Heat illness and heat stroke, Pediatr REV 28:249–258, 2007.

44. How quickly can temperature rise inside an enclosed automobile? The greatest rise in temperature in a closed vehicle occurs within the first 15 to 30 minutes. Leaving the window slightly open (“cracking the window”) does not affect the rapid temperature elevation. In one observational study, the internal temperature of an automobile increased by 40 °F compared with outside temperatures. Heat stroke is a significant cause of death in children who are left unattended in motor vehicles.

McLaren C, Null J, Quinn J: Heat stress from enclosed vehicles: moderate ambient temperatures cause significant temperature rise in enclosed vehicles, Pediatrics 116:e109–e111, 2005.

45. What are characteristics of heat stroke?
• Heatstroke occurs when the body temperature exceeds 104 °F, resulting in thermoregulatory collapse.
• Symptoms include: dizziness, disorientation, agitation, confusion, sluggishness, seizure, hot dry skin that is flushed but not sweaty, loss of consciousness, rapid heartbeat, and hallucinations.
• A core body temperature of 107 °F or greater can be lethal as cells are damaged and internal organs begin to shut down.

McLaren C, Null J, Quinn J: Heat stress from enclosed vehicles: moderate ambient temperatures cause significant temperature rise in enclosed vehicles, Pediatrics 116:e109–e111, 2005.

46. Why are children more vulnerable to effects of external temperature changes?
Children’s thermoregulatory systems are not as efficient as an adult’s and their body temperatures warm at a rate 3 to 5 times faster than an adult’s.
47. What are the signs and symptoms of significant upper airway heat exposure in a patient who has been in a house fire?
• Carbonaceous sputum
• Singed nasal hairs
• Facial burns
• Respiratory distress One should not rely on the presence of respiratory distress as an indicator for prompt endotracheal
intubation. The first three signs listed represent significant heat exposure to the airway, and progressive swelling can rapidly progress to upper airway obstruction.
48. What are the signs and symptoms of impending respiratory failure as a result of mucosal injury and edema from heat exposure during a house fire?
• Hoarseness
• Stridor
• Increasing respiratory distress
• Drooling and difficulty swallowing
An endotracheal tube should be emergently considered for patients with the above signs and symptoms. Upper airway mucosal swelling may make intubation difficult, and the most experienced physician should perform this intervention.
49. Which laboratory studies are needed for patients with suspected carbon monoxide (CO) poisoning?
• Blood carboxyhemoglobin (COHb) level
0% to 1%: Normal (smokers may have up to 5% to 10%)
10% to 30%: Headache, exercise-induced dyspnea, confusion
30% to 50%: Severe headache, nausea, vomiting, increased heart rate and respirations, visual disturbances, memory loss, ataxia
50% to 70%: Convulsions, coma, severe cardiorespiratory compromise
70%: Usually fatal
• Hemoglobin level: To evaluate correctable anemia
• Arterial pH: To detect acidosis
• Urinalysis for myoglobin: With CO poisoning, patients are susceptible to tissue and muscle breakdown with possible acute renal failure resulting from the renal deposition of myoglobin

50. What are the key aspects of treatment for carbon monoxide poisoning in children?
• Treatment includes 100% oxygen through non-rebreather mask until the COHb level falls to 5%. The half-life of COHb is 5 to 6 hours if the patient is breathing room air (at sea level). The half-life of COHb is reduced to 1 to 1½ hours if the patient is breathing 100% oxygen (at sea level). The half-life of COHb is reduced to under 1 hour with hyperbaric oxygen therapy.

• Refer for use of hyperbaric oxygen for the following conditions: a history of coma, seizure, or abnormal mental status at the scene or in the ED; persistent metabolic acidosis; neonate; pregnancy (the fetus is more vulnerable to hypoxic effects of CO); the HbCO level is more than 25%, even if the patient is neurologically intact.
51. Why is carbon monoxide such a deadly toxin?
• CO is odorless and invisible and can overwhelm a patient without warning.
• CO is ubiquitous as a product of partial combustion (car exhaust emissions, household heating equipment, burning charcoal).
• In the absence of a clear history, early CO intoxication is often misdiagnosed as a flulike illness.
52. What is the pathophysiology of carbon monoxide poisoning?
• CO develops a nearly irreversible bond with hemoglobin (with an affinity 200 to 300 times that of oxygen) that shifts the oxyhemoglobin dissociation curve to the left and changes its shape from sigmoidal to hyperbolic (with greatly diminished O2 tissue release).
• CO develops a strong bond with other heme-containing proteins, particularly in the mitochondria, thereby leading to metabolic acidosis and cellular dysfunction (especially in cardiac and CNS tissues).
53. What other serious exposure risk should one consider when managing a patient suffering from carbon monoxide poisoning?
One of the most important considerations in managing a CO-poisoned patient is concomitant cyanide (CN) poisoning. In CO-exposed patients with persistent acidosis and high lactate levels, one should seriously consider CN poisoning and treat accordingly. Supplemental oxygen therapy is not adequate. If CN poisoning is suspected, treat the patient with sodium thiosulfate.

Weaver LK: Carbon monoxide poisoning, N Engl J Med 360:1217–1225, 2009.

54. What are the different degrees of burn injuries?
See Table 5-2.

Table 5-2. Classification of Burn Wounds
DEGREE DEPTH CLINICAL APPEARANCE CAUSE
Superficial Epidermis Dry, erythematous Sunburn, scald
Partial Superficial dermis Blisters, moist, erythematous Scald, immersion, contact
Deep dermis White eschar Grease, flash fire
Full thickness Subcutaneous Avascular—white/dark, dry, waxy (yellow) Prolonged immersion, flame, contact, grease, oil
Muscle Charred, skin surface cracked Flame
Adapted from Coren CV: Burn injuries in children, Pediatr Ann 16:328–339, 1987.

55. How does the “rule of nines” apply in children?
The “rule of nines” is a tool used to estimate the extent of burns in adults. For example, in adults, the entire arm is 9% of the total body surface area (TBSA), the front of the leg is another 9% of the TBSA, and so on. The resulting estimate of the extent of burns is particularly helpful for calculating fluid requirements. Correction for age is necessary with this formula because of differing body proportions. Therefore, for children, use the surface of a patient’s palm, which represents about 1% of TBSA, as the tool for estimating the percentage of the TBSA affected by the burn (Fig. 5-5).

1-4 years

5-9 years

10-14 years

Adult

Figure 5-5. Rule of nines as applied to children. (CARVAJAL HF: Burn injuries. In Behrman RE editor: Nelson Textbook of Pediatrics, ed 14. Philadelphia, 1992, WB Saunders, p 235.)

56. Which burn injuries are indications for hospitalization?
• Partial-thickness burns covering more than 10% of the TBSA
• Full-thickness burns covering more than 2% of the TBSA
• Significant burns involving the hands, feet, face, joints, or perineum
• Burns resulting from suspected child abuse
• Electrical burns
• Circumferential burns (which may predispose the patient to vascular compromise)
• Explosion, inhalation, or chemical burns (in which other organ trauma may be involved)
• Significant burns in children younger than 2 years

Rodgers GL: Reducing the toll of childhood burns, Contemp Pediatr 17:152–173, 2000.

57. Why are alkali burns worse than acid burns in the eye? Alkali burns are caused by lye (e.g., Drano, Liquid-Plumr), lime, or ammonia, in addition to other agents; they are characterized by liquefaction necrosis. They are worse than acid burns because the damage is ongoing. When spilled in the eye, acid is quickly buffered by tissue and limited in penetration by precipitated proteins; coagulation necrosis results, which is usually limited to the area of contact. Alkali, however, has a more rapid and deeper advancement, thereby causing progressive damage at the cellular level by combining with membrane lipids. This underscores the importance of extensive irrigation of the burned eye, particularly in cases of alkali burns.
58. How do the injuries produced by lightning and high-voltage wires differ?
• Lightning: Consists of direct current of extremely high voltage (200,000 to 2,000,000,000 volts) delivered over milliseconds. Lightning exposure causes massive electrical countershock with asystole, respiratory arrest, and minimal tissue damage.
• High-voltage wires: Deliver alternating current of lower voltage (rarely exceeding 70,000 volts) over a longer period of time. High-voltage exposure causes ventricular fibrillation and deep tissue injury. The resultant muscle necrosis can lead to substantial myoglobin release and
renal failure.
59. In electrical injury, is alternating or direct current more hazardous? At low voltages (e.g., those found in household electrical devices), alternating current is more dangerous than direct current. Exposure to alternating current can provoke tetanic muscle contractions so
that the victim who has grasped an electrical source is unable to let go, thereby prolonging the exposure and producing greater tissue injury. Direct current or high-voltage alternating current typically causes a single forceful muscular contraction that will push or throw the victim away from the source.

60. What agents are the most common causes of anaphylaxis seen in U.S. emergency rooms?
Food. Peanuts, tree nuts (e.g., almonds, hazelnuts), and seafood head the list and are twice as common as bee stings as a trigger. Severe reactions occur 1 to 2 hours after exposure.
Anaphylaxis may occur without a skin reaction, so a high index of suspicion is needed in a child with unexplained sudden bronchospasm, laryngospasm, severe gastrointestinal (GI) symptoms,
or poor responsiveness. In some adolescents, certain foods (e.g., wheat, celery, shellfish), if ingested within 4 hours of exercise, can lead to food-dependent, exercise-induced anaphylaxis. Risk factors for fatal anaphylactic reactions include a history of asthma, delayed diagnosis, and delayed administration of epinephrine.

Rudders SA, Banerji A, Vassallo MF, et al: Trends in pediatric emergency department visits for food-induced anaphylaxis,
J Allergy Clin Immunol 126:385–388, 2010.
Lack G: Food allergy, N Engl J Med 359:1252–1260, 2008.

61. What are important considerations when treating frostbite in children?
• Rewarm the affected area in water with a temperature of 37 °C to 43 °C (99 °F to 109 °F) for 20 minutes.
• Never attempt to rewarm if there is risk for refreezing.
• Rubbing the affected area may cause further damage to tissue.

KEY POINTS: ENVIRONMENTAL INJURIES
1. Food (e.g., peanuts, tree nuts, seafood) is twice as common as insect stings as a cause of anaphylaxis in children.
2. Carbon monoxide poisoning is often misdiagnosed because the presenting symptoms can be flulike.
3. Consider cyanide poisoning in patients with CO exposure. If there is persistent acidosis and high lactate, initiate therapy with sodium thiosulfate.
4. Impending upper airway obstruction in house fires is more likely if there is the presence of carbonaceous sputum, singed nasal or facial hairs, or respiratory abnormalities (e.g., hoarseness, stridor).
5. Hospitalization is indicated for significant burns involving the hands, feet, joints, or perineum or if there are circumferential burns.
6. Alkali burns are worse than acid burns because of ongoing liquefaction necrosis.

RESUSCITATION
62. What are common problems identified in cardiopulmonary resuscitation (CPR) done by professionals?
• Numerous studies have demonstrated rates of compression are often inadequate.
• Chest wall decompression (the relaxation phase) is often incomplete.
• Chest compressions are often too shallow.
• Chest compressions are interrupted too frequently.
• Ventilation is excessive.

Sutton RM, Niles D, Nysaether J, et al: Quantitative analysis of CPR quality during in-hospital resuscitation of older children and adolescents, Pediatrics 124: 494–99, 2009.

63. What is the role for capnography during resuscitation?
Capnography, the monitoring of carbon dioxide, has been shown to be beneficial during cardiopulmonary resuscitation because it may provide feedback on the effectiveness of chest compressions. When available, it should be utilized. However, the readings need to be interpreted cautiously because vasoconstrictive medications, lung disease, and minute ventilation can affect the results.

64. Why is the airway of an infant or child more prone to obstruction than that of an adult?
• Infants have smaller airway diameters. Because airflow is inversely proportional to the airway radius raised to the fourth power (Poiseuille’s law), small changes in the diameter of the trachea can result in very large drops in airflow.
• The tracheal cartilage of an infant is softer and can collapse more easily if hyperextended.
• In an infant, the lumen of the oropharynx is relatively smaller, owing to the larger size of the tongue and smaller size of the mandible.
• Lower airways are smaller and less developed in children, thus putting them at risk for airway obstruction by small foreign bodies.

65. How can the correct size of endotracheal tubes (ETTs) be estimated for a given patient?
Pediatric advanced life support guidelines now recommend that cuffed tubes be used in most children beyond the neonatal period. When choosing a cuffed tube the formula [3.5 +(age in years/4)] is most commonly used. Another guideline is that the child’s pinky should approximate the internal diameter of the tube.
When choosing an uncuffed tube, one should estimate one half size larger, and the formula [4 +(age in years/4)] is appropriate. Because these formulas are estimates, it is advisable to have tubes one-half size larger and smaller available and prepared before intubation.

Kleinman ME, de Caen AR, Chameides L, et al: Part 10: Pediatric basic and advanced life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations, Circulation 122:S466–S515, 2010.
66. When should cuffed versus uncuffed ETTs be used? In the past, uncuffed ETTs were recommended for children younger than 8 years because of concern that the cuff could place excessive pressure on the already narrow portion of the pediatric cricoid cartilage. However, the American Heart Association has advised that both cuffed and uncuffed tubes are acceptable for infants and children undergoing emergent intubation. Cuffed tubes may even be preferable in those at high risk of aspiration, burn victims, and those with lung diseases that may necessitate higher ventilation pressures. When using a cuffed tube, care should be taken to avoid excessive cuff pressures.

67. How should the appropriate depth of an ETT be calculated? After insertion of an ETT, the appropriate depth (measured from the gum line) may be approximated using the following formula for children older than 1 year:
ðAge in years=2Þ + 12 cm
These measurements should always be confirmed by clinical means and radiography.
68. How should correct placement of an ETT be confirmed?
• Improvement or continued stability of vital signs including oxygen saturation
• Bilateral chest wall rise
• Bilateral symmetric breath sounds
• Absence of gastric insufflation sounds over the stomach
• Use of an exhaled CO2 detector device and continuous waveform capnography
• Direct laryngoscopy
• Chest radiography
69. What emergency drugs can be given through an ETT? Lidocaine, Epinephrine, Atropine, Naloxone (LEAN). Vasopressin can also be administered through an ETT. However, if available, intraosseous or intravenous administration is always preferable because

absorption is more predictable. The optimal dose of most drugs through the endotracheal route is not known. However, recommendations for epinephrine are 10 times the intravenous dose, and for other drugs, 2 to 3 times the intravenous dose. If drugs are being given through the ETT, they should be followed with 5 mL of normal saline and positive-pressure ventilation.

Kleinman ME, de Caen AR, Chameides L, et al: Part 14: Pediatric basic and advanced life support: 2010 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations, Circulation 122:S876–S908, 2010.

70. What are the potential reasons for acute deterioration in an intubated patient?
These can be remembered using the DOPE acronym:
• Displacement of the ETT
• Obstruction of the ETT
• Pneumothorax
• Equipment failure

American Heart Association: PALS PROVIDEr Manual, Dallas, 2006, American Heart Association, p 195.

71. When is atropine indicated during cardiopulmonary resuscitation?
Atropine is recommended as a premedication before laryngoscopy in infants. It may be administered to the child with symptomatic bradycardia with a pulse after other resuscitative measures
(i.e., oxygenation, ventilation, and epinephrine) have been initiated. Atropine may also be considered in cases of vagally induced bradycardia or anticholinergic poisoning.

72. When is the use of calcium indicated during cardiopulmonary resuscitation? Routine use of calcium is generally not recommended in resuscitation algorithms because it has not been shown to improve return of spontaneous circulation. Calcium use may be considered in the following specific situations:
• Overdose of a calcium channel blocker
• Hyperkalemia resulting in cardiac dysrhythmia
• Documented hypocalcemia
• Hypermagnesemia
• Hyperkalemia

73. What are contraindications to the use of an intraosseous line?
• Placement into a fractured bone
• Placement through dirty or infected skin
• Use in patients with bone disorders such as osteopetrosis or osteogenesis imperfecta
• Repeat attempt into the same bone (owing to risk for extravasation through the initial puncture site)

Blumberg SM, Gorn M, Crain EF: Intraosseous infusion: a review of methods and novel devices, Pediatr Emerg Care
24:50–56, 2008.

74. Can laboratory tests be obtained from intraosseous lines?
Compared with venipuncture, there appears to be a good correlation between serum and marrow electrolytes, hemoglobin, drug levels, blood group typing, and renal function tests. Correlation is poorer with liver function tests and arterial blood gas studies (PCO2 and PO2). Additionally, the positive correlations

appear to worsen after 30 minutes of CPR and/or drug and fluid administration. The most reliable samples on which to base clinical decisions would be those obtained at the time of intraosseous line placement early in the resuscitation.

Blumberg SM, Gorn M, Crain EF: Intraosseous infusion: a review of methods and novel devices, Pediatr Emerg Care
24:51, 2008.

75. What are the complications of intraosseous lines?
Significant morbidity is very uncommon (<1%). The most common problems are extravasation of fluids and superficial skin infections. Osteomyelitis is rare (<0.6%) and typically only occurs with prolonged infusions. Other rare complications are skin necrosis, bone fractures, and compartment syndrome.
Although there is the theoretical risk for significant bone growth arrest, growth plate damage, and fat embolism, these have not been reported. Obtaining venous access and discontinuing intraosseous infusions as soon as possible after stabilization have been recommended as means to further minimize complications.

Blumberg SM, Gorn M, Crain EF: Intraosseous infusion: a review of methods and novel devices, Pediatr Emerg Care
24:51, 2008.

76. What features indicate that an intraosseous needle has been correctly placed?
• A soft pop should be felt as you break through the cortex.
• The needle should be very stable.
• There should be free flow of intravenous fluids without infiltration of subcutaneous tissues.
• Bone marrow aspiration, although confirming placement, may not always be possible even when needle placement is correct. Therefore, if you cannot aspirate marrow, you should rely on other signs for determination of placement.
77. How can a child’s weight be estimated?
Some rules of thumb:
• An average term neonate weighs 3 kg
• An average 1-year-old weighs 10 kg
• An average 5-year-old weighs 20 kg The following formula may also be used:
Weight ¼ ð3 × ageÞ +7
New guidelines suggest that, in obese patients, medication doses should be calculated according to ideal body weight and should not be higher than recommended adult dosing.

78. Name the potentially reversible causes of cardiac arrest.
• H’s: Hypoxemia, hypovolemia, hypothermia, hyper/hypokalemia, hypoglycemia, and hydrogen ion (acidosis)
• T’s: Tamponade, tension pneumothorax, toxins, and thromboembolism

American Heart Association: PALS PROVIDEr Manual, Dallas, 2006, American Heart Association, p 178.

79. What are the typical clinical findings associated with supraventricular tachycardia (SVT)?
• Sudden onset
• Heart rate generally more than 180 beats per minute in children and more than 220 beats per minute in infants;
• Minimal heart rate variability

• Absent, abnormal, or inverted P waves
• Infants: Signs and/or symptoms that are nonspecific or, if SVT for hours or days, suggestive of congestive heart failure or shock (e.g., poor feeding, irritability, vomiting, cyanosis, pallor, cough, respiratory distress, lethargy)
• Verbal children: Palpitations and fluttering in the chest

Salerno JC, Seslar SP: Supraventricular tachycardia, Arch Pediatr Adolesc Med 163:268–274, 2009.

80. If an infant develops SVT, how long before congestive heart failure (CHF) develops? It is rare for an infant to develop CHF from SVT in less than 24 hours. When SVT is present for 24 to 36 hours, about 20% develop CHF. At 48 hours, the number increases to 50%.

Salerno JC, Seslar SP: Supraventricular tachycardia, Arch Pediatr Adolesc Med 163:268–274, 2009.

81. What factors may be predictive of outcomes after pediatric cardiac arrest?
Factors associated with IMPROVED likelihood of return of spontaneous circulation including:
• Short time to initiation of adequate CPR
• High quality CPR
• Shorter overall duration of resuscitation
• Witnessed cardiac arrest
Factors associated with poor outcomes include:
• Infants
• Obesity
• Initial nonperfusing rhythm
• Out-of-hospital traumatic arrest

82. Are fixed and dilated pupils a contraindication to resuscitation for a pediatric patient in cardiac arrest?
No. Pupillary dilation begins 15 seconds after cardiac arrest and is complete after about 1 minute and 45 seconds. It may only be a sign of transient hypoxia. The only absolute contraindications to resuscitation are rigor mortis, corneal clouding, dependent lividity, and decapitation.
83. When should a failing resuscitation be stopped?
Although there are no definitive guidelines, some studies have suggested that when more than two rounds of epinephrine have been given and/or more than 20 minutes have elapsed since the initiation of resuscitation without clinical cardiovascular or neurologic improvement, the likelihood of death or survival with neurologic devastation greatly increases. Unwitnessed out-of-hospital arrests are almost always associated with a poor outcome. In settings of hypothermia, patients should be rewarmed to 36 °C before resuscitation is discontinued. In patients with acute, reversible conditions such as drug toxicity or cardiac disease, extracorporeal cardiac life support may be considered if available.

American Heart Association: PALS PROVIDEr Manual. Dallas, 2006, American Heart Association, p 182.
Schindler M, Bohn D, Cox PN, et al: Outcome of out-of-hospital cardiac or respiratory arrest in children, N Engl J Med
335:1473–1479, 1996.

84. Why is resuscitation less successful in children than in adults?
Adults more commonly experience collapse and arrest from primary cardiac disease and associated dysrhythmias—ventricular tachycardia and fibrillation. These are more readily reversible and carry a better prognosis. Children, however, have cardiac arrest as a secondary phenomenon from other processes, such as respiratory obstruction or apnea, often associated with infection, hypoxia, acidosis, or hypovolemia. Primary cardiac arrest is rare. The most common dysrhythmia associated with pediatric cardiac arrest is asystole. It is less frequently reversible, and by the time a child has cardiac arrest, severe neurologic damage is almost always present.

85. Should family members be allowed to observe a resuscitation?
This has been a controversial topic with family members historically being excluded from the setting of an ongoing resuscitation. However, data are accumulating that indicate that the presence of family members (1) does not interfere with medical efforts or result in increased stress for the medical team or increased medicolegal conflicts and (2) is associated with a lesser likelihood of PTSD-related symptoms, including anxiety and depression, for those who observe resuscitation compared with those who don’t.

Jabre P, Belpomme V, Azoulay E, et al: Family presence during resuscitation, N Engl J Med 368:1008–1018, 2013.

SHOCK
86. Are all children in shock hypotensive?
No. Shock is an acute syndrome resulting from cardiovascular dysfunction that renders the circulatory system unable to provide oxygen and substrates to the body. In the initial stages of shock (compensated shock), blood pressure is often preserved. Physiologically, children will maintain a state of compensated shock until very late in the progression of illness.
87. What are the signs and symptoms of early or compensated shock?
• Unexplained tachycardia
• Mild tachypnea
• Delayed capillary refill
• Orthostatic changes in pressure or pulse
• Irritability
88. What are the signs and symptoms of late or uncompensated shock?
• Increased tachycardia
• Increased tachypnea
• Poor peripheral pulses
• Capillary refill markedly delayed
• Cool extremities
• Hypotension
• Altered mental status
• Low urine output
89. What external factors can affect the accuracy of measurement of capillary refill time in children and neonates?
• Room temperature: Children in a cool environment (19.4 °C) compared with those in a warmer environment (25.7 °C) will have a significantly prolonged (>2 seconds) capillary refill time (CRT). Seventy percent of healthy children in one study had prolonged CRT in the cooler environment but none had prolongation in the warmer environment.
• Ambient light: Darker conditions do impact the ability to make accurate visual determinations.
• Site of measurement: In neonates, CRT has been shown to be longer if it is measured in the heel compared with the head or sternum. Paradoxically, in older children, CRT was significantly faster when measured on the fingertip compared with the sternum.
• Pressure application: In neonates, application of pressure for 3 to 4 seconds significantly increases CRT compared with briefer periods (1 to 2 seconds) of pressure application. Most guidelines call for pressure application between 3 to 5 seconds.
• Interobserver reliability: When different observers measure CRT, studies have indicated agreement is not good, but improves with short (<1 second) or prolonged (>4 seconds) refill time.

King D, Morton R, Beran C: How to use capillary refill time, Arch Dis Child Educ Pract Ed 99:111–116, 2014.

90. How much blood volume can be lost before hypotension may be seen in children?
Some children can lose up to 30% of their blood volume before blood pressure noticeably declines. It is important to note that 25% of blood volume equals 20 mL/kg, which is only 200 mL in a 10-kg child. Losses >40% of blood volume cause severe hypotension that, if prolonged, may become irreversible.

91. What defines hypotension in children (i.e., systolic blood pressure <5th percentile for age)?
See Table 5-3.

Table 5-3. Hypotension in Children
AGE SYSTOLIC BLOOD PRESSURE (MM HG)
<1 month ≤60
1 month to 1 year ≤70
1 to 10 years ≤70 +(2 × age in years)
>10 years ≤90

92. What types of shock can occur in children?
• Hypovolemic: Decreased circulating volume (blood loss; fluid loss from gastroenteritis, most common cause in children)
• Distributive: Pooling of blood in peripheral vasculature (septic, anaphylactic, neurogenic)
• Cardiogenic: Cardiac dysfunction with decreased cardiac output (e.g., congenital heart disease, myocarditis, dysrhythmia)
• Obstructive: Mechanical obstruction of ventricular outflow tract (e.g., cardiac tamponade, tension pneumothorax)
93. What are the hallmarks of septic shock?
• Fever or hypothermia
• Metabolic acidosis
• Vasodilation: widened pulse pressure and/or hypotension, bounding pulses

Angus DC, van der Poll T: Severe sepsis and septic shock, N Engl J Med 369:840–851, 2013.

94. What are the key initial management items for septic shock?
Early recognition of sepsis and initiation of therapy is associated with improved outcome.
• Control and/or maintain airway
• Recognize poor perfusion and shock
• Push 20 mL/kg up to 60 mL/kg of isotonic crystalloid solution as rapidly as possible and within the first hour.
• If there is still evidence of shock or poor perfusion, begin vasoactive therapy at 1 hour

Dellinger RP, Levy MM, Rhodes A: Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012, Crit Care Med 41:580–637,2013.
Carcillo JA, Fields AI: Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock, Crit Care Med 30:1370, 2002.

95. Are corticosteroids recommended for the treatment of septic shock?
There have been some studies in adults suggesting that corticosteroids may be beneficial for the treatment of septic shock. Currently, corticosteroids are recommended only for children who may have fluid-resistant or catecholamine-resistant septic shock or who have a clear history or evidence of adrenal insufficiency. Even in these scenarios, use of steroids has not been convincingly shown to impart survival advantage in children.

Menon K, McNally JD, Choong K, et al: A systematic review and meta-analysis on the effect of steroids in pediatric shock,
Pediatr Crit Care Med 14:474–480, 2013.

96. What is the most important pharmacologic therapy for anaphylactic shock? Epinephrine. Epinephrine should be administered intramuscularly as soon as possible. Plasma concentrations of epinephrine appear to be highest when given intramuscularly in the thigh compared with subcutaneously or intramuscularly in the arm. If the patient has severe refractory symptoms and hypotension, epinephrine may be given as a continuous intravascular infusion. Failure to administer epinephrine quickly increases the risk for death from anaphylaxis.

Liberman DB, Teach SJ: Management of anaphylaxis in children, Pediatr Emerg Med 24:861–866, 2008.

97. What are the possible causes of shock in the newborn period?
The differential diagnosis is broad, but remember the mnemonic THE MISFITS:
• Trauma (nonaccidental and accidental)
• Heart disease and hypovolemia
• Endocrine (e.g., congenital adrenal hyperplasia)
• Metabolic (electrolyte)
• Inborn errors of metabolism
• Sepsis (e.g., meningitis, pneumonia, urinary tract infection)
• Formula mishaps (e.g., underdilution or overdilution)
• Intestinal catastrophes (e.g., volvulus, intussusception, necrotizing enterocolitis)
• Toxins and poisons
• Seizures

Brousseau T, Sharieff GQ: Newborn emergencies: the first 30 days of life, Pediatr Clin North Am 53:69–84, 2006.

98. A 4-day-old infant presents to the ED in shock with evidence of CHF and cyanosis. In addition to managing the airway and breathing, what is the first line of pharmacologic therapy?
This baby likely has congenital heart disease with a ductal-dependent lesion such as hypoplastic left heart syndrome or coarctation of the aorta. The baby will require prostaglandin E1 infusion to maintain the patency of the ductus arteriosus until corrective surgery can be performed.
99. What are the four classes of medications that can be used to support cardiac output?
• Inotropes: Increase cardiac contractility and often heart rate (e.g., dopamine, dobutamine, epinephrine)
• Vasopressors: Increase vascular resistance and blood pressure (e.g., higher-dose dopamine, epinephrine, norepinephrine, vasopressin)
• Vasodilators: Decrease vascular resistance and cardiac afterload and promote peripheral perfusion (e.g., sodium nitroprusside)
• Inodilators: Increase cardiac contractility and reduce afterload (e.g., milrinone)
100. An 8-year-old presents to the ED after falling headfirst into an empty swimming pool. His heart rate is normal, yet despite aggressive fluid resuscitation he remains hypotensive. CT scans of the chest, abdomen, pelvis and head reveal only a small cerebral contusion. What is the likely cause of his hypotension? This patient is most likely suffering from neurogenic shock. Loss of sympathetic tone prevents the expected tachycardic response. The hallmarks of neurogenic shock are hypotension with either bradycardia or a normal heart rate despite fluid replenishment. If the hypotension cannot be corrected with fluid expansion, vasopressor therapy may be required, and within the first 8 hours, corticosteroids may be considered.

KEY POINTS: SIGNS AND SYMPTOMS OF SHOCK
1. Tachycardia
2. Poor peripheral pulses
3. Slow capillary refill
4. Cool extremities
5. Hypotension
6. Altered mental status

KEY POINTS: SHOCK IN PEDIATRIC TRAUMA
1. Shock in pediatric trauma patients is often masked because the inherent reserve in a child allows for the maintenance ofvital signs for a longperiod of time, even in the presence ofsevere hemodynamic compromise.
2. Shock should be suspected in patients with tachycardia, a decrease in pulse pressure >20 mm Hg, skin mottling, cool extremities, delayed capillary refill (>2 seconds), and altered mental status.
3. The presence of hypotension in a child represents a state of uncompensated shock and indicates severe blood loss.
4. Shock is not explainable by head trauma alone, except in the case of an infant with open fontanels and unfused cranial sutures who may have a significant hemorrhage into the subgaleal or epidural space.
5. Shock may be associated with femur and/or pelvic fractures.
6. Shock should quickly prompt an evaluation of the child’s abdomen for the source of blood loss.

TOXICOLOGY
101. What are the most common poisonings in children younger than 6 years?
See Table 5-4.

Table 5-4. Common Poisonings in Children
NONPHARMACEUTICALS PHARMACEUTICALS
Cosmetics and personal care products Analgesics
Cleaning substances Cough and cold preparations
Plants, including mushrooms and tobacco Topical agents
Battery, toys, and other foreign bodies Vitamins
Insecticides, pesticides, and rodenticides Antimicrobials

102. Which medications can kill a 10-kg toddler with 1 or 2 tablets, capsules, or teaspoonfuls?
• Tricyclic antidepressants (amitriptyline, imipramine, desipramine)
• Antipsychotics (thioridazine, chlorpromazine)
• Antimalarials (chloroquine, hydroxychloroquine)
• Antiarrhythmics (procainamide, flecainide)
• Calcium channel blockers (nifedipine, verapamil)
• Oral hypoglycemics (glyburide, glipizide)
• Opioids (methadone, hydrocodone)
• Imidazolines (clonidine, tetrahydrozoline)

Bar-Oz B, Levichek Z, Koren G: Medications that can be fatal for a toddler with one tablet or teaspoonful, Paediatr Drugs
6:123–126, 2004.

103. What medication causes the most overdose deaths in children each year in the United States?
Acetaminophen. Large numbers of accidental and suicidal intoxications occur each year in part because of its widespread availability.

Hanhan UA: The poisoned child in the pediatric intensive care unit, Pediatr Clin North Am 55:669–686, 2008.

KEY POINTS: ACETAMINOPHEN OVERDOSE
1. Significant ingestions may have no initial symptoms.
2. Assess for co-ingestions.
3. Administer charcoal if ingestion was within 4 hours of treatment.
4. Assess plasma acetaminophen level at 4 hours after ingestion (if possible) and apply nomogram.
5. Administer the antidote N-acetylcysteine within 8 to 10 hours of ingestion.

104. Name the toxicology “time bombs.”
Time bombs are medications that lack symptoms early after ingestion but later have a profoundly toxic course.
• Acetaminophen (delayed hepatic injury)
• Iron (delayed cyanosis and profound metabolic acidosis)
• Alcohols—methanol (delayed acidosis), ethylene glycol (delayed nephrotoxicity)
• Lithium
• Anticonvulsants—phenytoin (Dilantin), carbamazepine
• Time-release medications
105. What empirical drug therapies are indicated for the poisoned child who presents with altered mental status?
All poisoned patients with depressed mental status should receive oxygen through a non-rebreather facemask. Blood glucose should be rapidly evaluated or empirical treatment for hypoglycemia with INTRAVENOUS glucose, 0.5 g/kg, initiated. Hypoglycemia is associated with ingestion of ethanol,
β-blockers, and oral hypoglycemic agents. Naloxone may be given as a diagnostic and therapeutic measure in the event of suspected or known opioid ingestion.
106. What is gastrointestinal decontamination?
Gastrointestinal decontamination refers to a variety of medications that may be administered and techniques that may be used to decrease the absorption of ingested poisons. Methods of gastrointestinal decontamination include activated charcoal, whole bowel irrigation, and gastric lavage. The effectiveness of these techniques is difficult to study, and much of the available evidence is based on animal and volunteer studies.
107. How does single-dose activated charcoal work and when should it be considered? Single-dose ACTIVATED charcoal is prepared as a liquid slurry and given orally to a poisoned patient. As it enters the stomach, it adsorbs toxins, thereby preventing absorption into the circulation. It is most efficacious when given within 1 hour of the time of ingestion. Single-dose activated charcoal may be considered in patients who have ingested a potentially toxic substance that is known to be adsorbed by charcoal within 1 hour of presentation. It is most likely to help children who may have ingested carbamazepine, dapsone, phenobarbital, quinine (Qualaquin), theophylline, salicylates, phenytoin,
or valproic acid (Depakene). Charcoal is contraindicated in patients whose airway reflexes are compromised, and it should not be given through nasogastric tube unless the airway is protected with an ETT because of the risk for aspiration.

American Academy of Clinical Toxicology, European Association of Poisons Centres and Clinical Toxicologists: Position statement: single-dose activated charcoal, J Toxicol Clin Toxicol 43:61, 2005.

108. For what substances is charcoal not recommended?
• Hydrocarbons, because of possible increased risk for aspiration
• Others: acids, alcohols, alkalis, cyanide, iron, heavy metals, and lithium

American Academy of Clinical Toxicology, European Association of Poisons Centres and Clinical Toxicologists: Position statement: single-dose activated charcoal, J Toxicol Clin Toxicol 43:61–87, 2005.

109. When is gastric lavage indicated? Gastric LAVAGE involves the passage of a large orogastric tube (e.g., 24-Fr orogastric for a toddler, 36-Fr orogastric for a teenager) with sequential administration and aspiration of small volumes of normal saline (10 mL/kg in a child; 200 to 300 mL in an adult) with the intent of removing toxic substances present in the stomach. Efficacy remains unproved, and complications are significant (e.g., laryngospasm, esophageal injury, aspiration pneumonia); it should not be used routinely. A position paper by the American Academy of Clinical Toxicology (AACT) and European Association of Poisons Centres and Clinical Toxicologists (EAPCCT) indicates that there is no evidence showing that gastric lavage should be used routinely, if at all, in the management of poisonings. Evidence for use in special situations (e.g., lethal ingestions, recent exposures, substance not bound to activated charcoal) is weak. If performed by well-practiced physicians, it may be considered for patients with a life-threatening quantity of a poisonous ingestion occurring within 60 minutes of evaluation if the patient’s airway is protected.

Benson BE, Hoppu K, Troutman WG, et al: Position paper update: gastric lavage for gastrointestinal decontamination, Clin Toxicol 51:140–146, 2013.

110. What are the indications for whole bowel irrigation (WBI) in acute ingestions?
This is a method of gastrointestinal decontamination using a large volume of polyethylene glycol– balanced electrolyte solution such as GoLYTELY given by mouth or nasogastric tube. These solutions are not known to cause electrolyte imbalance because they are neither significantly absorbed nor do they exert osmotic effect. WBI may be considered for toxic ingestions of sustained-release or enteric-coated medications. It may also be helpful in ingestions of large amounts of iron, or packets of illicit drugs. The most important contraindication to WBI is airway compromise. Although whole bowel irrigation may be helpful for those who have ingested heavy metals or long-acting or sustained-release medications, there are few clinical trials about the effectiveness of this procedure in children.

American Academy of Clinical Toxicology, European Association of Poisons Centres and Clinical Toxicologists: Position statement: whole bowel irrigation, J Toxicol Clin Toxicol 42:843–854, 2004.
111. How is the manipulation of urinary pH used in treating poisonings? Acidification or alkalinization of the urine to enhance the excretion of weak acids and bases has been a traditional way to enhance the elimination of toxicologic agents. In recent years, its use has been limited because of the potential complications from fluid overload (e.g., pulmonary and cerebral edema), the risk for acidemia, and the use of other therapeutic advancements (e.g., hemodialysis). However, alkaline diuresis is still considered valuable in the management of acute overdoses of salicylates, barbiturates, or tricyclic antidepressants.
112. What ingestions and exposures have available antidotes?
See Table 5-5.

Table 5-5. Antidotes
INGESTION OR EXPOSURE ANTIDOTE
Acetaminophen N-acetylcysteine (Mucomyst)
Anticholinergics Physostigmine
Benzodiazepines Flumazenil
β-Blockers Glucagon
Carbon monoxide Hyperbaric oxygen chamber
Calcium channel blocker Calcium, glucagon
Cyanide Sodium nitrite, sodium thiosulfate
Digoxin Digibind (antidigoxin antibody)
Ethylene glycol Ethanol, fomepizole
Iron Deferoxamine
Isoniazid Pyridoxine (vitamin B6)
Lead EDTA, DMSA
Mercury Dimercaprol, DMSA
Methanol Ethanol
Methemoglobinemic agents Methylene blue
Opiates Naloxone, nalmefene
Organophosphates Atropine, pralidoxime
Phenothiazines (dystonic reaction) Diphenhydramine
Tricyclics Bicarbonate
Warfarin (rat poison) Vitamin K
DMSA ¼ Dimercaptosuccinic acid; EDTA ¼ Ethylenediaminetetraacetic acid.

113. For which kinds of ingestions is naloxone considered an antidote?
Naloxone (Narcan) is an antidote for opioid drugs. It reverses the CNS and respiratory depression of morphine and heroin and clears the depressed sensorium in overdoses due to many of the
synthetic opioids, including propoxyphene, codeine, dextromethorphan, pentazocine, and meperidine. It is also a known antidote for clonidine.
114. Which ingestions are radiopaque on abdominal radiograph?
The mnemonic CHIPS indicates possible suspects.
• Chloral hydrate
• Heavy metals (arsenic, iron, lead)
• Iodides
• Phenothiazines, psychotropics (cyclic antidepressants)
• Slow-release capsules, enteric-coated tablets
The likelihood of radiopacity depends on numerous factors, including weight of the patient, size of the ingestion, and composition of the pill matrix.

Barkin RM, Kulig KW, Rumack BH: Poisoning and overdose. In Barkin RM, Rosen P, editors: Emergency Pediatrics, ed 4. St. Louis, 1994, Mosby, p 335.

Figure 5-6. Long-bone radiograph of both knees of a child with lead poisoning showing dense metaphyseal bands involving the distal femurs, proximal tibias, and proximal fibulas. (From Dapul H, Laraque D: Lead poisoning in children, Adv Pediatr 61:313–333, 2014.)

115. What causes the radiographic “lead lines” of chronic lead poisoning?
Lead lines are transverse metaphyseal bands most prominent at the end of longer tubular bones which are seen in the later stages of chronic lead exposure (see Fig. 5-6). They represent increased calcium (not lead) deposits. Excessive lead interferes with bone metabolism and disrupts the resorption of primary spongiosa bone by disproportionately disrupting osteoclasts, which are involved in bone disassembling, compared with osteoblasts, which participate in calcium deposition. As a result of lead toxicity and relative increased osteoblastic activity, there is an exuberant calcium deposition that results in the dense metaphyseal bands corresponding to the zone of provisional calcification.

Raber SA: The dense metaphyseal band sign, Radiology 211:773–774, 1999.

116. What is a toxidrome?
A toxidrome, short for a toxic syndrome, is a clinical constellation of signs and symptoms that is very suggestive of a particular poisoning or category of intoxication. For example, patients with

salicylate overdose commonly present with fever, hyperpnea and tachypnea, abnormal mental status (ranging from lethargy to coma), tinnitus, vomiting, and sometimes oil of wintergreen odor from methyl salicylate.

Koren G: A primer of paediatric toxic syndromes or “toxidromes”, Paediatr Child Health 12:457–459, 2007.

117. What is the toxidrome for anticholinergics?
The classic description of anticholinergic toxicity is “mad as a hatter, fast as a hare, red as a beet, dry as a bone, blind as a bat, full as a tick, hot as Hades.”
• The hatter: delirium, visual hallucinations
• The hare: tachycardia, hypertension
• The beet: flushed skin, facial flushing
• The bone: dry skin, dry mucous membranes
• The bat: dilated, sluggish pupils
• The tick: urinary retention, decreased GI motility, and hypoactive bowel sounds
• Hades: hyperpyrexia, inability to sweat

118. What breath odors may be associated with specific ingestions?
See Table 5-6.

Woolf AD: Poisoning in children and adolescents, Pediatr REV 14:411–422, 1993.

Table 5-6. Breath Odors Associated with Specific Ingestions
CHARACTERISTIC ODOR RESPONSIBLE TOXIN OR DRUG
Wintergreen Methyl salicylate
Bitter almond Cyanide
Carrots Cicutoxin (of water hemlock)
Fruity Ethanol, acetone (nail polish remover), isopropyl alcohol, chloroform
Fishy Zinc or aluminum phosphide
Garlic Organophosphate insecticide, arsenic, thallium
Glue Toluene
Minty Mouthwash, rubbing alcohol
Mothballs Naphthalene, p-dichlorobenzene, camphor
Peanuts Vacor rat poison (odor is from a flavoring agent)
Rotten eggs Hydrogen sulfide, N-acetylcysteine, disulfiram
Rope (burned) Marijuana, opium
Shoe polish Nitrobenzene

119. What are the limitations of the routine toxicology screen?
Most toxicology screens are intended to detect drugs encountered in substance abuse. Even in larger pediatric hospitals, comprehensive toxicology screens generally include only a fraction of drugs available to children. Most blood screens analyze for acetaminophen, salicylates, and alcohols. Urine is often screened for substances of abuse and other common psychoactive drugs, including antidepressants, antipsychotics, benzodiazepines, sedative-hypnotics, and anticonvulsants. Other potential toxins that can cause mental status changes (carbon monoxide, chloral hydrate, cyanide, organophosphates) or circulatory depression (β-blockers, calcium channel blockers, clonidine, digitalis) may not be included but may be assayed through individual blood tests.

In clinical studies, toxicology screens are most valuable in quantitative settings (i.e., assessing drug levels). Additionally, treatment of the acutely poisoned patient must begin long before the results of many toxicology screens are available.

Archer JRH, Wood DM, Bargan PI: How to use toxicology screening tests, Arch Dis Child Educ Pract Ed 97, 194–199, 2012. Moeller KE, Lee KC, Kissack JC: Urine drug screening: practical guide for clinicians, Mayo Clin Proc 83:66–76, 2008.

120. After use of marijuana, how long does a urine screen remain positive?
After first-time single use, the drug screen can be positive for 3 days. A long-term heavy marijuana user can have a positive drug test that may persist 30 days or more after cessation. Two cautions: nonsteroidal medications, including ibuprofen and proton pump inhibitors, have been reported to cross-react with cannabinoid immunoassays. False-negative results can occur if a wise teen adds Visine to a urine specimen. The chemicals in Visine directly lower the concentrations of the cannabinoids in the urine.

Moeller KE, Lee KC, Kissack JC: Urine drug screening: practical guide for clinicians, Mayo Clin Proc 83:66–76, 2008.

121. How do the types of alcohol ingestions vary?
All alcohols can cause CNS disturbances ranging from mild mentation and motor abnormalities to respiratory depression and coma. Each alcohol is associated with specific metabolic complications.
• Ethanol (present in beverages, colognes and perfumes, aftershave lotion, mouthwash, topical antiseptic, rubbing alcohol) in infants and toddlers can cause the classic triad of coma, hypothermia, and hypoglycemia, and in adolescents, can cause intoxication and mild neurologic findings. At levels higher than 500 mg/dL, it can be lethal.
• Methanol (present in antifreeze and windshield washer fluid) can cause severe, refractory metabolic acidosis and permanent retinal damage leading to blindness.
• Isopropyl alcohol (present in jewelry cleaners, rubbing alcohol, windshield deicers, cements, paint removers) can cause gastritis, abdominal pain, vomiting, hematemesis, and CNS depression, moderate hyperglycemia, hypotension, and acetonemia without acidosis.
• Ethylene glycol (present in antifreeze, brake fluid) causes severe metabolic acidosis. In addition, it is metabolized to oxalic acid, which can cause renal damage by the precipitation of calcium oxalate crystals in the renal parenchyma and can lead to hypocalcemia.

122. Which alcohol is considered the most lethal? Methanol. Deaths can arise from doses as little as 4 mL of pure methanol. Unique to methanol is that it becomes more toxic as it is metabolized. Methanol is broken down by alcohol dehydrogenase to formaldehyde and formic acid. It is the formic acid that causes the refractory metabolic acidosis and ocular symptoms.
123. What is the treatment for methanol and ethylene glycol ingestions?
Both methanol and ethylene glycol require the enzyme alcohol dehydrogenase to create their toxic metabolites. Ethanol competitively inhibits the formation of these metabolites by serving as a substrate for the enzyme. However, it is inebriating, may cause hypoglycemia, and its kinetics are widely variable. Fomepizole is a safer and more effective blocker of alcohol dehydrogenase.

Brent J: Fomepizole for ethylene glycol and methanol poisoning, N Engl J Med 360:2216–2223, 2009.

124. What is “MUDPILES”?
MUDPILES is a mnemonic for ingestions associated with a high anion gap metabolic acidosis.
• Methanol, metformin
• Uremia
• Diabetic ketoacidosis
• Paraldehyde
• Isoniazid, iron, inborn errors of metabolism
• Lactic acidosis (seen with shock, CO, cyanide)
• Ethanol, ethylene glycol
• Salicylates

125. How can pupillary findings assist in the diagnosis of toxic ingestions?
• Miosis (pinpoint pupils): Narcotics, organophosphates, phencyclidine, clonidine, phenothiazines, barbiturates, ethanol
• Mydriasis (dilated pupils): Anticholinergics (atropine, antihistamines, cyclic antidepressants); sympathomimetics (amphetamines, caffeine, cocaine, LSD, nicotine)
• Nystagmus: Barbiturates, ketamine, phencyclidine, phenytoin

126. If a child has ingested an acetaminophen-containing product, when should the first acetaminophen level be obtained?
A plasma level obtained 4 hours after ingestion is a good indicator of the potential for hepatic toxicity. Nomograms are available for determining risk. As a rule, doses under 150 mg/kg are unlikely to be harmful.

127. When should a “NAC attack” begin?
N-acetylcysteine (NAC) is a specific antidote for acetaminophen hepatotoxicity by serving as a glutathione substitute in detoxifying the hepatotoxic metabolites. It should be used for any acetaminophen overdose with a toxic serum acetaminophen level within the first 24 hours after ingestion. It is especially effective if used in the first 8 hours after ingestion. If acetaminophen levels are not available on a rapid basis or the time since ingestion is not clear, it is preferable to initiate NAC.

128. How does NAC prevent hepatotoxicity in acetaminophen overdose?
Normally, 94% of acetaminophen is metabolized to glucuronide or sulfate form, and 2%
is excreted unchanged in urine, both of which are nontoxic. The remaining 4% is conjugated with glutathione (with the help of cytochrome P-450) to form mercaptopuric acid, which is also not hepatotoxic. When a significant acetaminophen overdose occurs, cytochrome P-450
becomes the major system for metabolizing the acetaminophen, leading to depletion of hepatic stores of glutathione. When the glutathione is depleted to less than 70% of normal, a highly reactive intermediate metabolite binds to hepatic macromolecules, causing hepatocellular necrosis. It is presumed that NAC replenishes the glutathione, thus helping the cytochrome P-450 in converting the excess acetaminophen into mercaptopuric acid.

Heard KJ: Acetylcysteine for acetaminophen poisoning, N Engl J Med 359:285–292, 2008.

129. What arterial blood gas pattern is classic for salicylate poisoning?
Metabolic acidosis and respiratory alkalosis. Salicylates directly stimulate the medullary respiratory drive center, causing tachypnea with diminished PCO2 (respiratory alkalosis). They also cause lactic acidosis and ketoacidosis by inhibiting Krebs cycle enzymes, uncoupling oxidation phosphorylation, and inhibiting amino acid metabolism (metabolic acidosis).

130. What are hidden salicylates?
These are salicylates that are found in over-the-counter products, such as Pepto-Bismol (bismuth salicylate). Salicylate absorption can be substantial, and in the setting of influenza or chickenpox, Pepto-Bismol use has been discouraged because of the potential for complications such as the development of Reye syndrome.

Szap MD: Hidden salicylates, Am J Dis Child 143:142, 1989.

131. What are the classic ECG findings associated with tricyclic antidepressants? Tricyclic antidepressants interfere with myocardial conduction and can precipitate ventricular tachycardias or complete heart block. A QRS interval >0.1 second is predictive of poor outcome in these patients. The presence of a large R wave in lead aVR is also associated with tricyclic antidepressants. If these findings are noted, treatment with sodium bicarbonate should be initiated. Sodium bicarbonate helps prevent the sodium channel blockade that is caused by these medications. Of note, diphenhydramine (Benadryl), if ingested in high doses, can mimic the ECG findings of tricyclic antidepressants.

132. Which clinical and laboratory features correlate with an acutely elevated serum iron?
Serum iron levels obtained 4 to 6 hours after ingestion correlate with severity of toxicity. Iron levels >300 μg/dL are associated with mild toxicity consisting of local GI symptoms, such as nausea, vomiting, and diarrhea. A serum iron level of 500 μg/dL is associated with
serious systemic toxicity, and a level of 1000 μg/dL is associated with death. Other laboratory tests that correlate with an elevated iron level include leukocytosis (>15,000/mm3) and hyperglycemia (>150 mg/dL). Sometimes, radiopaque tablets may be demonstrated on abdominal radiograph.

133. What are the four clinical stages of iron toxicity and the correlating pathophysiology?
• Stage 1 (0.5 to 6 hours): During this stage, iron exhibits a direct corrosive effect on the small bowel. Symptoms include nausea, vomiting, abdominal pain, and/or GI hemorrhage.
• Stage 2 (6 to 24 hours): Iron silently accumulates in the mitochondria; the patient is relatively symptom free.
• Stage 3 (4 to 40 hours): This phase is characterized by systemic toxicity with shock, metabolic acidosis, depressed cardiac function, and hepatic necrosis.
• Stage 4 (2 to 8 weeks): During this phase, pyloric stenosis and obstruction can develop as a result of earlier local bowel irritation.

134. Which is more toxic, drinking dishwashing detergent or toilet bowl cleaner? You are better off with the toilet bowl cleaner, although both acid (toilet bowl cleaner) and alkali (dishwashing detergent) ingestions may cause severe esophageal burns. Alkalis cause injury by
liquefaction necrosis, dissolving proteins and lipids, thereby allowing deeper penetration of the caustic substance and greater local tissue injury. With acids, coagulation necrosis of the tissue occurs. This results in the formation of an eschar that limits the penetration of the toxin into deeper tissues.
Compared with acids, alkalis are more typically in solid and paste form, which increases tissue contact time and tissue injury.

135. Which hydrocarbons pose the greatest risk for chemical pneumonitis?
The household hydrocarbons with low VISCOSITIEs pose the greatest aspiration hazard. These include furniture polishes, gasoline and kerosene, turpentine and other paint thinners, and lighter fuels.

136. What is the differential diagnosis in a child who presents with confusion and lethargy?
An altered state or level of consciousness can be due to many causes. The mnemonic AEIOU TIPS
encompasses the many possible causes:
• Alcohol, abuse of substances
• Epilepsy, encephalopathy, electrolyte abnormalities, endocrine
• Insulin, intussusception
• Overdose, oxygen deficiency
• Uremia
• Trauma, temperature abnormality, tumor
• Infection
• Poisoning, psychiatric conditions
• Shock, stroke, space-occupying lesion (intracranial)

Avner JR: Altered states of consciousness, Pediatr REV 27:331–337, 2006.

137. A patient receiving an antiemetic drug (e.g., promethazine) who develops involuntary, prolonged, twisting, writhing movements of the neck, trunk, and arms likely has what condition?
Acute dystonia. This dystonic reaction is classically seen as an adverse side effect of antidopaminergic agents such as neuroleptics, antiemetics, or metoclopramide. In children, phenothiazines are the most common culprit. Treatment includes administration of diphenhydramine (Benadryl). Benztropine (Cogentin) is also used in adolescents.

138. What do “SLUDGE” and “DUMBELS” have in common?
Both are mnemonics used to remember the problems involved with organophosphate poisoning, lipid-soluble insecticides used in agriculture and terrorism (“nerve gas”). Organophosphates inhibit cholinesterase and cause all the signs and symptoms of acetylcholine excess.
• Muscarinic effects are increased oral and tracheal secretions, miosis, salivation, lacrimation, urination, vomiting, cramping, defecation, and bradycardia; may progress to frank pulmonary edema.
• CNS effects are agitation, delirium, seizures, and/or coma.
• Nicotinic effects: Sweating; muscle fasciculation; and ultimately, paralysis
• The mnemonic SLUDGE is salivation, lacrimation, urination, defecation, GI cramps, and emesis.
• The mnemonic DUMBELS is defecation, urination, miosis, bronchorrhea/bradycardia, emesis, lacrimation, and salivation.
139. What metal intoxication can mimic Kawasaki disease?
Mercury. Acrodynia is the term applied to one form of mercury salt intoxication that results in a constellation of signs and symptoms very similar to that currently recognized as Kawasaki disease. The classic presentation of acrodynia was described in children exposed to calomel, a substance used in teething powders, which was essentially mercurous chloride. The symptom complex included swelling and redness of the hands and feet, skin rashes, diaphoresis, tachycardia, hypertension, photophobia, and an intense irritability with anorexia and insomnia. Infants were often very limp, lying in a froglike position, with impressive weakness of the hip and shoulder girdle muscles. Similar symptoms have been described in children exposed to other forms of mercury, including broken fluorescent light bulbs or diapers rinsed in mercuric chloride.
140. Why is cyanide so toxic?
Cyanide ion binds to the heme-containing cytochrome as enzyme in the electron transport chain of mitochondria, which is the final common pathway in oxidative metabolism. Thus, with a significant exposure, virtually every cell in the body becomes starved of oxygen at the mitochondrial level and is unable to function. The body does have minor routes of cyanide detoxification, including excretion by the lungs and liver through rhodanese, a hepatic enzyme that combines cyanide with thiosulfate to form the less toxic thiocyanate for renal excretion. However, these mechanisms are inadequate in the face of a significant cyanide exposure. As with carbon monoxide poisoning, symptoms tend
to be most prominent among the metabolically active organ systems. In particular, the CNS is rapidly affected, causing headache and dizziness, which may progress to prostration, convulsions, coma, and death. Less severe ingestions may be noted initially by burning of the tongue and mucous membranes, with tachypnea and dyspnea due to cyanide stimulation of chemoreceptors.
141. In what settings should cyanide poisoning be suspected?
• Suicidal ingestion, often involving chemists who have access to cyanide salts as reagents
• Fires causing combustion of materials such as wool, silk, synthetic rubber, polyurethane, and nitrocellulose, resulting in the release of cyanide
• Patients who are on nitroprusside continuous infusion, an antihypertensive agent that contains five cyanide moieties per molecule
142. What kinds of plants account for the greatest percentage of deaths due to plant poisonings?
Mushrooms account for at least 50% of deaths due to plant poisoning. The most dreaded variety is the Amanita species, which initially causes intestinal symptoms by one toxin (phallotoxin) and then hepatic and renal failure by a separate toxin (amatoxin). Other mushroom classes can cause a variety of early-onset (<6 hours) symptoms, including muscarinic effects (e.g., sweating, salivation, colic), anticholinergic effects (e.g., drowsiness, mania, hallucinations), gastroenteritis, and Antabuse-type effects if taken with alcohol.
143. Is mistletoe toxic?
Mistletoe, the popular Christmas plant, is an evergreen with small white berries. Ingestion of small amounts of the berries, leaves, or stems may result in GI symptoms, including pain, nausea, vomiting, and diarrhea. Rarely, large ingestions have resulted in seizures, hypertension, and even cardiac arrest. In some countries, extracts of mistletoe have been used for illegal abortifacients, brewed in teas that are particularly toxic. In the United States, the typical call to a poison center concerns a child who eats one or two mistletoe berries, which in general is unlikely to produce significant signs or symptoms.

144. Should swallowed disc batteries be removed?
Although the concern is that a disc battery may produce corrosive intestinal injury, most traverse the GI tract without incident. An initial radiograph for localization is indicated. If the disc battery is in the esophagus, removal is required. Otherwise, if the battery is in the stomach or beyond and the patient remains asymptomatic, watchful waiting is appropriate with follow-up imaging if the battery is not seen in the stool.

Litovitz T, Whitaker N, Clark L, et al: Emerging battery-ingestion hazard: clinical implications, Pediatrics
125:1168–1177, 2010.

145. What are the available methods used to remove a foreign body from the esophagus?
Three methods are used; local custom prevails regarding selection.
• Esophagoscopy, the most commonly used method, is done under general anesthesia.
• A Foley catheter can be inserted beyond the foreign body, inflated, and then pulled back to remove the object. This extraction method is used by various centers, particularly for coins if the ingestion is less than 24 hours old and no respiratory distress is present. Complications, such as airway obstruction by a displaced coin and esophageal perforation, are possible.
• In bougienage, the object is forced into the stomach.

146. What recreational drug is most frequently associated with rave parties?
Rave parties are large parties or festivals featuring live performances of electronic dance music, laser light shows, projected images, visual effects, and smoke machines. A number of drugs are associated with these events, including LSD and ketamine, but the drug that is most associated with rave parties is MDMA (popularly known as ecstasy or Molly), a psychoactive drug that has similarities to both the stimulant amphetamine and the hallucinogen mescaline.

147. Why is ecstasy considered so dangerous?
Ecstasy is rarely sold as pure ecstasy and often includes other drugs that the user may not be aware of; therefore, its effects are not predictable. The pure form (known as Molly for “molecular”) can cause tachycardia, dry mouth, teeth grinding, and clenched jaw. Severe adverse reactions
to the drug include pronounced hyperthermia, seizures, hypertensive crises, dysrhythmias, metabolic disturbances, DIC, rhabdomyolysis, acute kidney disease, liver toxicity, and stroke.
It has also been known to be fatal in some cases. Care is supportive and usually involves some form of cooling.

KEY POINTS: TOXICOLOGY
1. Ipecac is no longer recommended for poisoning.
2. Activated charcoal is most efficacious if given within 1 hour of ingestion.
3. Gastric lavage has unproven efficacy for most ingestions.
4. Whole bowel irrigation is indicated for sustained-release or enteric-coated substances.
5. Alkalinization of urine is still considered valuable in the management of acute overdoses of salicylates, barbiturates, or tricyclic antidepressants.

TRAUMA
148. What are the major signs of a blowout fracture?
Traumatic force to the eye can result in a blowout fracture affecting either the orbital floor or the medial wall (Fig 5-7). The fracture may result from a sudden increase in intraorbital pressure or from a direct concussive force to the bony walls. Symptoms and signs can include the following:
• Pain and/or diplopia with upward gaze
• Compromised upward gaze on the affected side as a result of entrapment of the inferior rectus muscle
• Enophthalmos (i.e., posterior displacement of the globe of the eye)
• Loss of sensation over the upper lip and gums on the injured side
• Crepitus and tenderness over the inferior orbital ridge

Figure 5-7. Waters view (A) shows polypoid soft-tissue mass in the roof of the left antrum (arrow), which was a blowout fracture of the orbital floor. Coronal CT scan (B) shows the herniated soft tissues (arrow) of the blowout fracture. (From Som PM, Curtin HD, editors: Head and Neck Imaging, ed 5. Philadelphia, 2011, Mosby, p. 513.)

149. When evaluating a patient with an eye injury, when should you suspect a ruptured globe and how should you handle it?
Globe rupture denotes a full-thickness laceration of the cornea and/or sclera. This is an ophthalmologic emergency and must be recognized immediately. The hallmark clinical features include:
• Tear drop pupil
• 360-degree subconjunctival hemorrhage
• Enophthalmos
If globe rupture is suspected, an ophthalmologist should be emergently consulted and the acronym SANTAS should be followed:
• Shield should be placed over the eye to protect from further damage.
• Antiemetics should be given to protect against increased pressure.
• NPO (nothing per oral, or by mouth) to prepare for surgery.
• Tetanus shot should be given.
• Analgesics, either parenteral or oral (avoid topical), should be administered.
• Sedation, if not contraindicated by other injuries, should be given.

Levin AV: Eye trauma. In Fleischer GR, Ludwig S, editors. Textbook of Pediatric Emergency Medicine, ed 6. Philadelphia, 2010, Wolters Kluwer, pp 1448–1453.
Rahman WM, O’Connor TJ: Facial trauma. In Barkin RM, Caputo GL, editors: Pediatric Emergency Medicine, Concepts and Clinical Practice. St. Louis, 1997, Mosby, pp 252–253.

150. When should an avulsed tooth be reimplanted?
Avulsion is the complete displacement of the tooth from its socket. Primary teeth (i.e., baby teeth) should not be reimplanted because nerve root damage or dental ankylosis may result. Secondary teeth should be repaired as soon as possible to maximize the chance of tooth viability. An avulsed tooth may be stored in cold milk, saline, or placed under a cooperative patient’s tongue and should be reimplanted as quickly as possible.

Bernius M, Perlin D: Pediatric ear, nose and throat emergencies, Pediatr Clin North Am 55:209–210, 2006.

151. What are the three most important considerations when evaluating nasal trauma?
• Bleeding: If persistent, bleeding should be controlled with pressure, ice, topical vasoconstrictors, cauterization, and anterior or posterior nasal packing.
• Septal hematoma: If the nasal septum is bulging into the nasal cavity, there is likely a hematoma that must be drained. If drainage is not performed, abscess formation or pressure necrosis can result and lead to a saddle-nose deformity.
• Watery rhinorrhea: This may be a sign of cribriform plate, suborbital ethmoid, sphenoid sinus, or frontal sinus fracture with cerebrospinal fluid leak.

152. How long can you wait before a broken nose in a child must be reduced?
If a nasal bone fracture causes asymmetry (which is noted as the swelling from acute trauma subsides), the fracture should be reduced within 4 to 5 days; a longer delay may result in mal-union.
153. After a motor vehicle collision, an 8-year-old presents with right-sided pain, a heart rate of 150 beats per minute, a blood pressure of 110/80 mm Hg, and capillary refill time of 3.5 seconds. How should his initial fluid therapy be managed?
It is important to recognize that this child is in shock, despite a normal blood pressure for age.
For children in shock, changes in blood pressure are often late and precipitous. Findings of tachycardia, prolonged capillary refill, and diminished pulses are indicative of intravascular HYPOVOLEMIA in this patient, requiring aggressive fluid resuscitation. Isotonic crystalloid (saline or lactated Ringer solution) should be given in boluses of 20 mL/kg over 5 to 10 minutes. If, after 40 mL/kg of crystalloid, hemodynamic measures have not improved or have worsened, blood products should be given in 10 mL/kg boluses.
154. What are the signs and symptoms of a tension pneumothorax?
A tension pneumothorax presents with hypotension, respiratory distress, diminished breath sounds on the affected side, and tracheal deviation. Treatment begins with emergent needle decompression in the second intercostal space at the midclavicular line followed by chest tube placement.
155. Which children with acute minor blunt head trauma require emergency CT scans? The largest prospective study of children younger than 18 years (>42,000 patients) with head trauma was designed to determine which patients are at very low risk for clinically important traumatic brain injury for whom CT is unnecessary. Derived prediction rules were developed
based on age. Negative predictive values (i.e., the likelihood of something not being present, in this case significant brain injury) were 100% for the younger group and 99.95% for the older group (and thus CT was thought to be unnecessary) if the following characteristics were seen on evaluation:
• Younger than 2 years: Normal mental status, no scalp hematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 seconds, nonsevere injury mechanism (e.g., fall of less than 3 feet, motor vehicle collision without patient ejection or death of another passenger, no head injury by high-impact object), no palpable skull fracture, acting normally according to parents
• Aged 2 years and older: Normal mental status, no loss of consciousness, no vomiting, nonsevere injury mechanism, no signs of basilar skull fracture, no severe headache

Kuppermann N, Holmes JF, Dayan PS, et al: Identification of children at very low risk of clinically important brain injuries after head trauma: a prospective cohort study, Lancet 374:1160–1170, 2009.

156. What is the risk associated with CT scans in children?
The ionizing radiation of CT scans may be implicated as the cause of lethal malignancies. Using data from the cancer rates after the atomic bomb blasts in Japan in World War II and comparing that degree of radiation and sequelae with CT radiation, it is estimated that the potential rate of lethal malignancies from pediatric cranial CT may be between 1/1000 and 1/1500. This highlights the need to obtain CT studies with appropriate clinical indications and to limit the amount of radiation
to be as low as possible during the procedure.

Brenner DJ, Hall EJ: Computed tomography—an increasing source of radiation exposure, N Engl J Med 35: 2277–2284, 2007.

157. When intracranial pressure is acutely elevated, how long is it before papilledema develops?
Generally, 24 to 48 hours may pass before papilledema develops.
158. What are the components of the Glasgow Coma Scale (GCS)?
Developed in 1974 by the neurosurgical department at the University of Glasgow, the scale was an attempt to standardize the assessment of the depth and duration of impaired consciousness and

coma, particularly in the setting of trauma. The scale is based on eye opening, verbal responses, and motor responses, with a total score that ranges from 3 to 15 (Table 5-7).

Table 5-7. Glasgow Coma Scale
Best Verbal Response*
5 Oriented, appropriate conversation 4 Confused conversation
3 Inappropriate words
2 Incomprehensible sounds
1 No response
Best Motor Response to Command or to Pain (e.g., rubbing knuckles on sternum)
6 Obeys a verbal command 5 Localizes
4 Withdraws
3 Abnormal flexion (decorticate posturing)
2 Abnormal extension (decerebrate posturing) 1 No response
Eye Opening
4 Spontaneous
3 In response to verbal command 2 In response to pain
1 No response
*Children <2 years old should receive full verbal scores for crying after stimulation.

159. How does the location of cervical spine fractures vary between younger children and older children and adults?
Younger children tend to have fractures of the upper cervical spine, whereas older children and adults have fractures more often involving the lower cervical spine, for the following reasons:
• Changing fulcrum of the spine: In an infant, the fulcrum of the cervical spine is at approximately C2-C3; in a child who is 5 to 6 years old, the fulcrum is at C3-C4; from
8 to adulthood, it is at C5-C6. These changes are in large part the result of the relatively large head size of a child compared with that of an adult.
• Younger children have relatively weak neck muscles.
• Younger children have poorer protective reflexes.

Woodward GA: Neck trauma. In Fleisher GR, Ludwig S, editors: Textbook of Pediatric Emergency Medicine, ed 6. Philadelphia, 2010, Wolters Kluwer, pp 1379–1380.

160. What is SCIWORA?
SCIWORA stands for Spinal Cord Injury Without Radiographic Abnormality. SCIWORA is most commonly seen in children >8 years of age. These patients have signs and symptoms that are consistent with spinal cord injury, but radiographic and CT studies reveal no bony abnormalities. It is postulated that the highly malleable pediatric spine allows the cord to sustain injury from flexion-extension forces without causing bony disruption. MRI often reveals spinal cord injury in
these cases. The initial neurologic complaints of these children should be taken seriously because onset of SCIWORA can be delayed up to 4 days. Even with normal radiographs, a patient with an altered sensorium or with neurologic abnormalities that are consistent with cervical cord injury (e.g., motor or sensory changes, bowel and bladder problems, vital sign instability) requires continued neck immobilization and more extensive evaluation.

161. Are single lateral cervical spine radiographs sufficient to “clear” a patient after neck injury?
No. In some studies, the sensitivity of a single view for fractures is only 80%. The American College of Radiology guidelines recommend at least three views: (1) anteroposterior (including the
C7-T1 junction, C1-C7), (2) lateral, and (3) open mouth (odontoid). The last view is often difficult to obtain in younger children. CT and MRI are reserved for more extensive evaluation for spinal cord injury when the initial three views are negative in symptomatic patients. The use of oblique films is controversial.

Hutchings L: Clearing the cervical spine in children, Trauma 13:340–352, 2011.
Eubanks JD, Gilmore A, Bess S, et al: Clearing the pediatric cervical spine following injury, J Am Acad Orthop Surg
14:552–564, 2006.

162. Why is left shoulder pain after abdominal trauma a worrisome sign?
This may represent blood accumulating under the diaphragm, resulting in pain referred to the left shoulder (Kehr sign). The sign can be elicited by left upper quadrant palpation or by placing the patient in the Trendelenburg position. The finding is worrisome because it suggests possible solid organ abdominal injury—most commonly splenic injury—and requires surgical consultation and radiographic studies (usually CT or ultrasound) to grade the extent of injury.

Lee J, Moriarty KP, Tashjian DB: Less is more: management of pediatric splenic injury. Arch Surg 147:437–441, 2012.

163. A 5-year-old child has ecchymosis of the lower abdomen after a motor vehicle collision. What should you immediately suspect?
This child’s injuries should immediately key you in to the possibility of a lap-belt injury. In children who are either too young (<8 years old) or too small, the lap belt of a car rests abnormally high on the child’s body and, instead of crossing the lap at the hips, crosses the lap at the lower abdomen. The most common injuries to suspect are lumbar spine injuries, particularly a flexion disruption (Chance) fracture and bowel or bladder perforations or disruptions.

Santschi M, Echave V, Laflamme S, et al: Seat-belt in children involved in motor vehicle crashes, Can J Surg
48:373–376, 2005.

164. In a 7-year-old boy with a radiographically proven pelvic fracture, what diagnostic procedure should be done?
The urethra, as it passes through the prostate, is very close to the pubic bone and is thus susceptible to injury from a pelvic fracture. Urethral damage should be suspected in all patients with pelvic fractures, even those without hematuria. The recommended diagnostic procedure
is a retrograde urethrogram.
165. In this same patient as in question 164, blood at the tip of the penis is noted. Why is catheterization contraindicated?
A boggy, high-riding prostate found on rectal examination and blood seen at the urethral meatus are clinical signs of possible urethral disruption; these two findings are contraindications for passing a Foley catheter. A partial urethral disruption could potentially be made into a complete one with the passing of the catheter.

166. What is the focus of the FAST examination?
FAST stands for focused assessment with sonography in trauma. It is used as a screen for abdominal and pericardial bleeding as blood appears black (hypoechoic) against the bright (hyperechoic) background of the internal organs. A FAST exam evaluates four principal areas for bleeding: the pericardial sac, the hepatorenal fossa (Morrison pouch), the splenorenal fossa,
and the pelvis (pouch of Douglas). This noninvasive tool provides clinicians with rapid information about potentially life-threatening thoracic and abdominal injury. In victims of blunt abdominal trauma who are unstable, a positive FAST examination may be an indication that the patient needs urgent surgical intervention.

Levy JA, Bachur RG: Bedside ultrasound in the pediatric emergency department, Curr Opin Pediatr
20:235–242, 2008.

167. In children with blunt abdominal trauma, are there clinical findings that predict low risk of clinically important injury?
The PECARN research network prospectively enrolled 12,000 children following blunt abdominal trauma. If the following predictors were present, the rule correctly identified 99% of the children as low risk:
• No evidence of abdominal wall trauma or seat belt sign
• GCS score >13
• No abdominal tenderness
• No evidence of thoracic wall trauma
• No complaints of abdominal pain
• No decreased breath sounds
• No vomiting

Holmes JF, Lillis K, Monroe D, et al: Identifying children at very low risk of clinically important blunt abdominal injuries.
Ann Emerg Med 62:107–116, 2013.

WOUND REPAIR
168. What advice should be given over the telephone regarding the transportation of an avulsed digit?
Wrap the severed piece in dry gauze (sterile, if possible). Place the wrapped piece in a small, sealed plastic bag to minimize its contact with water. Place this bag in a container filled with ice. It is incorrect to place the avulsed piece in any liquid because this causes tissue swelling. Direct contact with ice is to be avoided to prevent tissue necrosis.

169. Which lacerations should be referred to a surgeon or an ED physician who is familiar with wound repair?
• Large, complex lacerations
• Stellate or flap lacerations
• Lacerations with questions of tissue viability
• Lacerations involving lip margins (vermilion border)
• Deep lacerations with nerve or tendon damage
• Knife and gunshot wounds
• Strong concern about cosmetic outcome by either the patient or the family
• Lacerations involving open fractures or joint penetration
• Lacerations involving the inner eyelid, owing to the potential of damage to the tear ducts
• Deep lacerations involving the cheek, owing to potential damage to the parotid or facial nerve
170. How many days should sutures remain in place?
Blood supply dictates healing: the more blood, the better and the faster the healing. In general, as the site of laceration proceeds, from head to toe, the less blood supply there is and the greater the duration for suture placement: eyelids—3 days; face, scalp—5 days; trunk, upper extremities—7 to 10 days; and lower extremities—8 to 10 days.
171. When should a nerve injury be suspected in a finger laceration?
• Abnormal testing of sensation (diminished pain or two-point discrimination)
• Abnormal autonomic function (absence of sweat or lack of skin wrinkling after soaking in water)
• Diminished range of motion of finger (may also indicate joint, bone, or tendon disruption)
• Pulsating blood emerging from the wound (on the flexor aspect, the nerve is superficial to the digital artery, and arterial flow implies nerve damage)
172. What should be done if nerve damage is suspected?
For injuries to major nerves (e.g., the brachial plexus), immediate consultation is necessary. If the digital nerve is injured, immediate repair is not essential, and this is not a true emergency. Delayed nerve repair is very satisfactory, particularly in younger children. If an operating suite and personnel are not poised to proceed, skin closure can be done and the operation deferred (after surgical

consultation). Care must be taken to avoid the use of a hemostat or clamp to stop arterial bleeding because this may cause further damage to the nerve. Simple pressure—often for extended periods— generally suffices.
173. Which lacerations should not be sutured?
Lacerations at high risk for infection should be considered for healing by secondary intention or delayed primary closure. As a general rule, these include cosmetically unimportant puncture
wounds, human bites, lacerations involving mucosal surfaces (e.g., mouth, vagina), and wounds with a high probability of contamination (e.g., acquired in a garbage bin). Many authorities in the past recommended that wounds untreated for more than 6 to 12 hours on the arms and legs and for 12 to 24 hours on the face not be sutured. However, the type of wound and risk
for infection are more important than any absolute time criterion. For example, a clean laceration
of the face should be considered for suturing even 24 hours after the injury. A good rule of thumb is as follows: If you can irrigate and clean a wound to the point at which it looks “fresh,” you are safe to close it primarily. Otherwise, you should let it heal by secondary intention.

KEY POINTS: LACERATIONS
1. The best defense against infection in the setting of wound closure is copious irrigation.
2. Irrigation can be painful and should be done after local anesthetic is applied or infiltrated.
3. Irrigation can be done with a number of different fluids, including sterile water, normal
saline or tap water, but should not be done with betadine-containing fluids, which are abrasive to the tissue.
4. There is no one universal suture material that is good for all wounds. The material should be chosen based on location, size, and depth of the wound and the tensile strength that is required to easily appose the wound edges.
5. Suspect digital nerve injury if there is abnormal sensation, abnormal autonomic function, diminished range of motion of finger, or pulsating blood emerging from the wound.

174. Which are at greater risk for infection, dog bites or cat bites?
Generally, infection rates are higher in cat bites because of the greater likelihood of a puncture wound rather than a laceration injury. Additionally, Pasteurella multocida, which is the most common pathogen responsible for infection, is present in higher concentrations in cat bites.
Wounds caused by cat and dog bites usually contain multiple other organisms, including
Staphylococcus aureus; Moraxella, Streptococcus, and Neisseria species; and anaerobes.

Kannikeswaran N, Kamat D: Mammalian bites, Clin Pediatr 48:145–148, 2009.
Talon DA, Citron DM, Abrahamian FM, et al: Bacteriologic analysis of infected dog and cat bites, N Engl J Med
340:85–92, 1999.

175. Should antibiotic prophylaxis be given for dog, cat, and human bites?
This is a controversial topic. Although antibiotics are widely prescribed following mammalian bites, prophylactic antibiotics have been shown to significantly reduce infections in only two settings: bites to the hands and human bites. Some experts recommend treatment for other “high-risk” injuries such as cat bites, foot wounds, puncture wounds, wounds in immunocompromised patients, and wounds treated initially after 12 hours. It is important that all such wounds first be irrigated, cleaned, and débrided as necessary.

Singer AJ, Dagum AB: Current management of acute cutaneous wounds, N Engl J Med 359:1037–1046, 2008.

176. Which animals most often carry the rabies virus?
Although all species of animals are susceptible to rabies virus infection, only a few species are important as reservoirs for the disease. In the United States, rabies has been identified most commonly in raccoons, skunks, foxes, coyotes, and bats.

Center for Disease Control and Prevention Rabies Domestic Animal Surveillance: www.cdc.gov/rabies/location/usa/ surveillance/domestic_animals.html. Accessed on Nov. 19, 2014.

177. Which are more likely to be rabid: cats or dogs?
During 2000 to 2004, more cats than dogs were reported rabid in the United States. This may be due to the facts that there are fewer cat vaccination laws, fewer leash laws with cats, and cats tend to roam more freely than dogs.

Center for Disease Control and Prevention Rabies Domestic Animals: www.cdc.gov/rabies/exposure/animals/domestic. html. Accessed Nov. 19, 2014.

178. If at a local petting zoo a playful 20-month-old child is bitten by a duck, scratched by a rabbit (breaking skin), spit on by a camel, and licked on the face by a horse, should rabies prophylaxis be given?
In general, no prophylaxis is needed for any of these animal wounds unless the animal is actively rabid. The local health department should be contacted if there is any question. Immediate rabies vaccination and rabies immune globulin are recommended for bites or scratches from bats, skunks, raccoons, foxes, and most other carnivores if these injuries break the skin. Bites from dogs and cats generally do not necessitate prophylaxis if the animal is healthy and can be observed closely for a 10-day period. No case in the United States has been attributed to a dog or cat that has remained healthy for the confinement period of 10 days.

American Academy of Pediatrics: Rabies. In Pickering LK, editor: 2012 Red Book, ed 29. Elk Grove Village, IL, 2012, American Academy of Pediatrics, pp 600–607.

179. When is the use of lidocaine with epinephrine contraindicated as a local anesthetic?
Lidocaine with epinephrine is contraindicated when there is a question of tissue viability and in any instance in which vasoconstriction might produce ischemic injury to an end organ without an alternative blood supply (e.g., tip of the nose, margin of the ear, tip of the finger or toe).
180. What are methods for decreasing the pain of local lidocaine infiltration?
• Infiltration into the subcutaneous layer
• Infiltration at a slow rate
• Buffering the anesthetic (e.g., with bicarbonate; there is no magic formula, but one that works is 10 parts lidocaine and 1 part bicarbonate)
• Warming the anesthetic to body temperature
• Using a small-gauge needle (e.g., 30 gauge)
• Distraction techniques
181. What are some of the ingredients in the alphabet soup of topical anesthetics?
• LET (4% lidocaine, 0.1% epinephrine, and 0.5% tetracaine)
• TAC (tetracaine, adrenaline, and cocaine)
• LMX (4% and 5% lidocaine gel)
• V-TAC (viscous TAC)
• PLP (prilocaine, lidocaine, and phenylephrine)
• EMLA (eutectic mixture of local anesthetics, typically lidocaine and prilocaine)
TAC was among the first of these to be developed, but its higher costs and safety concerns (as a result of the cocaine component) have resulted in others, particularly LET, replacing it as first-line therapy. The American Academy of Pediatrics recommends the use of topical anesthetics, such as LET, for simple lacerations of the head, neck, and extremities, or trunk <5 cm in length. Systemic toxicity can occur through excessive absorption of topical anesthetics; however, this can be minimized by avoiding mucosal membranes and large open wounds.

Zempsky WT: Pharmacologic approaches for reducing venous access pain in children, Pediatrics 122:S140–S153, 2008.

182. When should tissue adhesives be considered or avoided?
Consider tissue adhesives for the following:
• Wounds with good edge approximation and little wound tension
• Wounds that are clean and linear
• Wounds that ordinarily, if sutured, would require sutures 5-0 or smaller (i.e., wounds with little tension)

AVOID tissue adhesives for the following:
• Wounds where good edge approximation cannot be achieved (e.g., jagged wounds)
• Bite or puncture wounds
• Generally, wounds deeper than 5 mm
• Hands, feet, or joints, unless the affected area can be immobilized
• Oral mucosa or other mucosal surfaces, or areas with increased amounts of moisture as in the perineum or axilla
• Patients with conditions that may delay wound healing (e.g., diabetes mellitus or patients on long-term steroids)
183. In which situations might you choose absorbable over nonabsorbable sutures when repairing a pediatric laceration?
An absorbable suture is generally one that loses most of its tensile strength in 1 to 3 weeks and is fully absorbed within 3 months. Traditionally, absorbable sutures were used only for deep sutures. However, recently, the use of absorbable sutures for percutaneous closure of wounds in adults and children has been advocated. The advantages of absorbable sutures include the elimination of a follow-up visit to remove the patient’s sutures and the possibility of decreased scarring and infection. Ideal wound candidates for absorbable sutures include the following:
• Facial lacerations, where skin heals quickly and prolonged intact sutures may lead to a suboptimal cosmetic result. (Fast absorbing sutures, which become absorbed in less than 1 week, are particularly good on facial wounds.)
• Percutaneous closure of lacerations under casts or splints
• Closure of lacerations of the tongue or oral mucosa
• Hand and finger lacerations
• Nail bed lacerations
184. What is the proper fluid to use for wound irrigation?
Normal saline, sterile water, or even tap water may be used. The key appears to be the
flushing action, rather than the fluid. Some authors argue that for a number of reasons—availability, low cost, efficiency, and effectiveness—tap water should be strongly considered for wound cleansing in the ED. However, other cleansing solutions, antiseptics such as betadine and
alcohol, remain controversial because of toxic effects on tissue and lack of significant clinical benefit.

Cooper DD, Seupaul RA: Is water effective for wound cleansing? Ann Emerg Med 60:626–627, 2012.

185. How is conscious sedation best managed in children? There is no single best method for the conscious sedation of pediatric patients for diagnostic, radiologic, or minor surgical procedures. Surveys indicate that a wide variety of approaches are used in emergency rooms and radiology suites, including opioids (morphine, fentanyl), benzodiazepines (diazepam, midazolam), barbiturates (pentobarbital, thiopental), and nonbarbiturate anesthetic-analgesic agents (ketamine). Although conscious sedation, by definition, is a state of medically controlled depressed consciousness with a patent airway, maintained protective reflexes, and appropriate responses to stimulation on verbal command, the potential for rapidly developing problems should be anticipated. These can include hypoventilation, apnea, airway obstruction, and cardiorespiratory collapse. Consequently, pharmacologic agents used for conscious sedation should be administered under supervised conditions and in the presence of competent personnel who are capable of resuscitation, ongoing monitoring (especially pulse oximetry), and sufficient equipment for resuscitation (e.g., positive- pressure oxygen delivery system, suction apparatus). As a rule, few office settings are appropriate for conscious sedation.

Sury M: Conscious sedation in children. Contin Educ Anaesth Crit Care Pain 12:152–156, 2012.
Mandt MJ, Roback MG: Assessment and monitoring of pediatric procedural sedation, Clin Pediatr Emerg Med
8:223–231, 2007.

Acknowledgment
The editors gratefully acknowledge contributions by Drs. Jane Lavelle and Fred Henretig that were retained from previous editions of Pediatric Secrets.

BONUS QUESTIONS
186. To reduce the exposure to radiation from a complete skeletal survey, can the survey be modified to include fewer x-rays than the full complement?
Not yet, but there is research being done on this. The spine and pelvis views have the lowest yield in revealing fractures and they require the largest amounts of radiation of all the views. Some researchers believe these views could be eliminated without missing cases of abuse.
They advocate for a stepwise approach to imaging that would protocolize a “core” skeletal survey, without lateral spine and pelvis, but would encourage inclusion of these views if clinically indicated. The complicating factor is that fractures of the spine and pelvis are highly specific for abuse when they are found. Some researchers believe it would be dangerous to eliminate these views from the initial skeletal survey.

Lindberg DM, Harper NS, Laskey AL, et al: Prevalence of abusive fractures of the hands, feet, spine, or pelvis on skeletal survey, Pediatr Emerg Care 29:26–29, 2013.
Karmazyn B, Lewis ME, Jennings SG, et al: The prevalence of uncommon fractures on skeletal surveys performed to evaluate for suspected abuse in 930 children: should practice guidelines change? Am J Radiol 197: W159–W163, 2011.

187. If physical abuse is suspected, are physicians mandated to photograph physical findings?
No. A good drawing of the physical findings is sufficient. However, if photographs are taken, a card with the patient’s name and date of birth and the photographer’s name and signature
must be included in the photograph so that the patient can be clearly identified. In addition, the body part that is being photographed must be clearly identifiable. If abuse is suspected, it is not necessary to obtain parental consent to take photographs.

188. If a toddler suffers a full-thickness burn to the corner of the mouth after biting an electrical cord, what complications might ensue?
Severe burns of the oral commissure can become markedly edematous within the first several hours. An eschar develops at the site, which can detach and cause significant bleeding from the labial artery 1 to 3 weeks later. Scarring can be extensive, and plastic surgeons should be consulted early during the management of this kind of injury.

189. What is a laryngeal mask airway (LMA)?
An LMA is an alternative device that can be used to ventilate children if the use of a bag valve mask is unsuccessful and an ETT is unable to be placed. It consists of an inflatable silicone mask and rubber connecting tube. It is inserted blindly into the pharynx, forming a low-pressure seal around the laryngeal inlet and permitting gentle positive-pressure ventilation. It does not confer the same protection against aspiration as an ETT, nor is it as stable; however, in an emergency situation, it may be considered as a rescue device.

190. What is the Sellick maneuver?
The Sellick maneuver is the application of pressure on the cricoid ring during rapid sequence intubation in order to prevent aspiration. There is no clinical evidence that cricoid pressure reduces aspiration, and there is some evidence that it can make intubation more difficult by distorting the airway landmarks. If cricoid pressure is used during intubation, the American Heart Association recommends that it be stopped if intubation or ventilation is difficult.

191. Should activated charcoal be given to a sleepy 2-year-old girl who consumed half a bottle of a liquid antihistamine 2 hours before evaluation?
No. This child has a potentially compromised airway because of her altered mental status. In addition, the effectiveness of activated charcoal is known to decrease rapidly with time.
Therefore, in this clinical scenario, the risks of administering charcoal and potentially causing vomiting and aspiration outweigh the benefits.

192. When can a toddler who may have swallowed some multivitamins be discharged home?
The toxic compound in multivitamin overdose is iron. A large variety of children’s chewable multivitamins contain different amounts of elemental iron (0 to 18 mg of elemental iron per tablet). The toxic dose of iron ingestion is at least 20 mg/kg of elemental iron, and the lethal dose of iron reported is in the range of 60 to 180 mg/kg of elemental iron. In a small child, a toxic dose is about 300 mg of elemental iron, which is the equivalent of 20 tablets of multivitamins containing 15 mg/tab of elemental iron. Frequently, the amount of ingestion is not known. Because iron can initially cause nausea, vomiting, or abdominal pain, a child with a suspected but unknown amount of iron poisoning can be observed, and an iron level may be obtained. A child who has no complaints and has a normal physical examination after 4 to 6 hours of observation can be
safely discharged home.
193. If the abdominal CT scan is negative in a patient with blunt abdominal trauma, can you be certain that there is no intra-abdominal injury?
No. CT scans may miss some bowel, diaphragmatic, and pancreatic injuries. If the CT shows free fluid in the abdominal cavity but no obvious organ injury, there may be injury to the gastrointestinal tract or the mesentery. Worsening abdominal pain or persistent emesis requires serial examinations, possible repeat CT scan, and at the discretion of the surgeon, exploratory laparotomy.

Wegner S, Colletti JE, Van Wie D: Pediatric blunt abdominal trauma, Pediatr Clin North Am 53:243–256, 2006.

194. In children with blunt thoracic trauma, are there clinical exam findings that predict low risk of significant injury?
A prospective clinical prediction rule identified the following clinical predictors for very low risk of thoracic injury in children with good sensitivity:
• Normal systolic blood pressure
• Normal respiratory rate
• Normal thoracic examination
• Normal chest auscultation
• No femur fracture
• GCS score of 15

Holmes JF, Sokolove PE, Brant WE, et al. A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma, Ann Emerg Med 39: 492–499, 2002.

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