EM Cases Digest Vol 2 Pediatric Emergencies PDF

THE MAGAZINE SERIES FOR ENHANCED EM LEARNING
Vol. 2: Pediatric Emergencies

BY ANTON HELMAN & TARYN LLOYD
THE MAGAZINE SERIES FOR ENHANCED EM LEARNING
Vol. 2: Pediatric Emergencies

BY ANTON HELMAN & TARYN LLOYD
Copyright © 2016 by Medicine Cases
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As medicine is a rapidly changing field, new diagnostic and treatment modalities
are likely to arise. It is the responsibility of the treating physician, relying on
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are not responsible for errors or omissions, or for any consequences from
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OUR THANKS TO...
EDITORS-IN-CHIEF
Anton Helman
Taryn Lloyd
PRODUCTION EDITOR
Michelle Yee
PRODUCTION MANAGER
Garron Helman
CHAPTER WRITERS PODCAST SUMMARY EDITORS

Sean Caine Niran Argintaru
Lincoln Foerster Lucas Chartier
Anna MacDonald Keerat Grewal
Michael Misch Claire Heslop
Meeta Patel Michael Kilian
Robyn Shafer
Rob Simard REVIEW QUESTIONS AUTHORS
Ahmed Taher David Homuth
Rajani Vairavanathan Areej Shahbaz
PODCAST GUEST EXPERTS

Alyssa Abo Anna Jarvis Lawrence Richer
Samina Ali Eric Letovsky Jennifer Riley
Alex Arroyo Sanjay Mehta Dennis Scolnik
Sarah Curtis Angelo Mikrogianakis Adam Sivitz
Anthony Crocco Gina Neto Rahim Valani
Jason Fischer Jonathan Pirie Amy Drendel
Stephen Freedman Sarah Reid
University of Toronto, Faculty of Medicine
EM Cases is a venture of the Schwartz/

Reisman Emergency Medicine Institute.
We’d like to thank our colleagues at SREMI
for their support and encouragement.
ACKNOWLEDGEMENTS
I would like to thank my wife, Sasha, and my children Emma and Rowan for
their ceaseless patience and support; my brother Garron for his dedication and
advice; my brother Wayne for the original website and logo design; my mentor,
Walter Himmel, for his inspiration, friendship, and advice; the EM Cases
Advisory Board for their guidance; the EM Cases team (Lucas Chartier, Teresa
Chan, Justin Morgenstern, Michael Misch, Claire Heslop, Keerat Grewal, Taryn
Lloyd, Michelle Yee, Lincoln Foerster, and Michael Kilian) for their hard work and
dedication; Mike Cadogan for his inspiration to join the FOAMed community and
his unparalleled altruism; the Schwartz/Reisman Emergency Medicine Institute
(Howard Ovens for his support and wisdom; Bjug Borgundvaag, Shirley Lee,
and Shelley McLeod for their support and team spirit); Kuldeep Sidhu for his
leadership, support, and patience; all of the guest experts for their incredible
knowledge and wisdom; the FOAMed community for teaching me and for its
egalitarian spirit; and the EM Cases audience for your honest feedback and the
inspiration to keep EM Cases growing. I feel immensely fortunate to have had
the opportunities that have allowed to me to learn, and educate others, in a
profession that is continually blossoming.
Anton Helman, MD, CCFP(EM), FCFP

Assistant Professor, University of Toronto
Department of Family & Community Medicine
Staff Physician, North York General Hospital, Department of Emergency
Medicine
Education Innovation Lead, Schwartz-Reisman Emergency Medicine Institute
Founder, Editor-in-Chief, and host of Emergency Medicine Cases
Thanks to TREKK for its partnership in recruiting

the pediatric emergency guest experts for the
podcasts and for the needs assessment from
which the topics were chosen.
FOREWORD
Social media technologies are game-changers in health professions education.
In the past several years, social media technologies have begun challenging how
traditional academic institutions think about education delivery and teaching.
Expensive textbooks, classroom-based teaching, and siloed workshops are
competing with the growing presence of open-access blogs, podcasts, and
global online journal clubs for learner attention. New communities of practice
are appearing constantly, connected by the Internet.
EM Cases was one of the first podcasts I noticed at the forefront of this
movement. When it launched in 2010, I was immediately impressed by the high-
quality content and attention to detail. I am not surprised to see that it currently
garners an amazing 90,000+ downloads per month. Its popularity is a reflection
of the how today’s busy lifelong learners consume medical knowledge. In
a word, it is—opportunistically. With so many digital distractors and an
overwhelming amount of medical information to keep abreast of in today’s
world, education delivery needs to be portable, easily accessible, and digestible
in chunks. Thus podcasts provide an appealing solution for the busy learner,
who may wish to listen while driving to work or exercising.
As a blogger, however, I am keenly aware that blogs and podcasts generally

provide a rather haphazard delivery of content to learners. I am guilty of that. I
publish what is most timely and relevant in the eyes of my editorial team. There
is no set curriculum framing the periodic release of new materials, and generally
each blog post is a standalone lesson. But can’t we, as educators, do better?
EM Cases can. The launch of the EM Cases Digest series is a huge step toward
structuring the modern learning experience using social media technology. This
marks the evolution of EM Cases from a podcast resource to a premiere podcast-
enhanced educational curriculum. While many podcast organizations have brief
show notes for their podcasts, none that I know of has created a professionally
designed ebook, integrating podcasts into a thoughtfully organized framework
of text- and image-based lessons with question-and-answer sections.
FOREWORD (Continued)
From a pedagogical and instructional design standpoint, this innovative

approach makes sense. It optimizes and solidifies learning based on Mayer’s
cognitive theory of multimedia learning. Incorporating both visual (ebook) and
auditory (podcast) elements optimizes working memory and thus learning.
Congratulations to Dr. Anton Helman and his EM Cases Digest team, who are at
the forefront of reimagining health professions education. I can only imagine
the ginormous effort that went into producing such a product with an eye
toward visual design, education theory, and multimedia integration. The result
is an ebook series that is fun, educational, and a joy to read. Thank you for
your dedication and pioneering vision for advancing education in emergency
medicine.
Your friend and fan,

Michelle
Michelle Lin, MD
Academy Endowed Chair of Emergency Medicine
Professor of Emergency Medicine
University of California, San Francisco;
Editor-in-Chief
Academic Life in Emergency Medicine blog (http://aliem.com)
@M_Lin
Guide to EM Cases Digest
We hope you will find the EM Cases Digest series to be an interactive, flexible, and en-
gaging way to enhance your emergency medicine learning journey. These ebooks are
intended to be an adjunct to the EmergencyMedicineCases.com podcasts, as well as to
existing emergency medicine curricula and resources. For optimal learning, we suggest
EM Cases Digest be used in conjunction with the podcasts for spaced, repetitive learning,
and as an interactive workbook, through which you can explore the links, videos, and
original resources (links to original references can all be found on our website). We en-
courage you to attempt the Q&As actively, revealing expert answers only after formulat-
ing your own answers and opinions.
Here’s a little description

to help explain all of the
graphics in this book:
Clinical Pearls:
Nuggets of wisdom
Clinical Ah-Has
Pearls Pitfalls Pitfalls:
Common regrets
Ah-Has:
Wow moments
Tools & Rules:
Clinical decision tools
and rules
Caution:
Warning; badness ahead
Tools Expert Expert Opinion:
Caution Opinion
What our guest experts
& Rules think when the evidence is
unclear
Key References:
EBM game-changers
What would you do?:
Reflect on what you would
do in your practice
Your Comments:
Key Your
Go to the linked blog post
What would to leave your comment
References you do? Comments
1
JUMP TO CHAPTER...
Chapter 1: Fever Without a Source Page 4

Link to the podcast with Sarah Reid and Gina Neto
Chapter 2: Sepsis and Septic Shock Page 22

Link to the podcast with Sarah Reid and Gina Neto
Chapter 3: Pain Management Page 35

Link to the podcast with Samina Ali and Anthony Crocco
Chapter 4: Head Injury Page 53

Link to the podcast with Rahim Valani and Jennifer Riley
Chapter 5: Pediatric Procedural Sedation Page 68

Listen to the podcast with Amy Drendel
Chapter 6: Orthopedic Injuries Page 82

Link to the podcast with Sanjay Mehta and Jonathan Pirie
Chapter 7: POCUS Nerve Blocks Page 106

Link to the podcast with Jason Fischer
Chapter 8: Abdominal Pain and Appendicitis Page 117

Link to the podcast with Anna Jarvis and Stephen Freedman
Chapter 9: POCUS Appendicitis and Intussusception Page 132

Link to the podcast with Adam Sivitz and Alex Arroyo
Chapter 10: Gastroenteritis, Constipation and Obstruction Page 143

Link to the podcast with Anna Jarvis and Stephen Freedman
JUMP TO CHAPTER...
Chapter 11: Diabetic Ketoacidosis Page 168

Link to the podcast with Sarah Reid and Sarah Curtis
Chapter 12: Bronchiolitis Page 183

Link to the podcast with Dennis Scolnik and Sanjay Mehta
Listen to the bonus podcast with Amy Plint
Chapter 13: Asthma Page 197

Link to the podcast with Dennis Scolnik and Sanjay Mehta
Chapter 14: Lung POCUS Page 212

Link to the podcast with Alyssa Abo
Chapter 15: Croup Page 221
Chapter 16: Pediatric Syncope Page 230

Link to the podcast with Eric Letovsky and Anna Jarvis
Chapter 17: Pediatric Seizures Page 250

Link to the podcast with Lawrence Richer and Angelo Mikrogianakis
Rapid Review Questions Page 269

EM CASES DIGEST - VOL. 2: PEDIATRIC EMERGENCIES
CHAPTER 1:
FEVER WITHOUT A
SOURCE
LISTEN TO THE PODCAST WITH SARAH REID AND GINA NETO HERE
Objectives
1. Understand the principles of fever management
2. Identify abnormal vital signs in the setting of pediatric fever
3. Have an approach to the investigation of UTI in children
4. Develop an approach to the child with fever without a source
5. Know when to order a full septic workup versus a partial septic workup
4
EM Cases Digest - Vol. 2: Pediatric Emergencies
Approximately 20% of children who present to the ED with fever will have
fever without a source despite your thorough history and physical exam.
A small but significant number of this 20% without an identifiable source of

fever will have an occult bacterial infection—UTI, bacteremia, pneumonia,
or even the dreaded early bacterial meningitis. These are all defined as
serious bacterial infections (SBI), with occult UTI being the most common SBI
(especially in children under the age of two years).
In the old days, we used to do a full septic workup including LP for all infants
under the age of three months; thankfully, times have changed in the
post-Haemophilus and pneumoccocal vaccine age, and we aren’t quite so
aggressive any more with our workups. Nonetheless, it’s still controversial
as to which kids need a full septic workup, which kids need a partial septic
workup, which kids need just a urine dip, and which kids need little except to
reassure the parents.
5
CASE 1:
FEVER PRINCIPLES
A 12-month-old girl is brought in to your ED with three days of fever between
38.5°C and 40°C. She is previously healthy, immunizations are up to date
(including Haemophilus and pneumococcal vaccines), and there has been
no recent travel. She has no cough, no difficulty breathing, no vomiting, no
apparent belly pain, no rash, and no diarrhea. She’s been eating and drinking
well at home.
Q: Does this child require a rectal temperature measurement?

Which children with suspected fever require a rectal temperature
measurement in the ED?
A: As rectal temperatures are the most accurate estimation of core body

temperature compared with axillary, oral, and ear temperatures, and missing
fever in younger children may carry high morbidity, it is recommended that a
rectal temperature be obtained in all neonates, infants, and toddlers (younger
than three years old) who present to the ED with suspected fever or with an
undefined illness that could be the result of an infection/sepsis.
Q: The parents are very concerned that the “very high fever” of their
12-month-old girl might cause brain damage or represent a serious
illness. This is a common concern. How do you counsel the parents?
A: Fever itself is the body’s natural response to fighting infection, and does not
inherently cause harm. Children with infection as a cause of their fever almost
never mount a fever high enough to be dangerous (> 41.5°C); these very high
temperatures are typically seen only in non-infectious causes of hyperthermia.
In terms of predicting bacteremia, the precise height of the Video:

fever is not as important as the duration of the fever. A fever Click here to see
of 39.8°C that has lasted for two days is not as concerning as a Dr. Anthony Crocco’s
fever of 38.2°C that has lasted for six days in terms of the risk of rant on fever
bacteremia. phobia.
6
Q: This child has a rectal temperature of 39°C.

Do we need to treat this child’s fever in the
Clinical Pearl:
ED?
A parent’s assessment of A: While this temperature is not inherently

fever by touch has been dangerous to the child, there are benefits to treating
shown to correlate fairly fever. Lowering the temperature of a febrile child not
well with a true fever. A only provides comfort and minimizes dehydration,
child who is brought in but treating the fever also allows for more accurate
for a “tactile fever” but prognostication when the now afebrile child is re-
who is afebrile in the ED examined. When a child changes from being irritable
still warrants a thorough or lethargic to active, playful, and alert after receiving
assessment for sources an antipyretic for their fever, you can usually be
of fever. Be sure to ask less concerned about an SBI. If the child’s vital signs
if the child received an and clinical picture continue to be concerning when
antipyretic prior to your afebrile, then an SBI should be suspected.
assessment.
Q: Which is the better antipyretic:
acetaminophen or ibuprofen?
Expert Opinion: A: Studies show that ibuprofen is superior at treating

both fever and pain in children.
To avoid potential
toxicities, our experts Caution! Combining ibuprofen and
recommend no more acetaminophen may be a more effective
than three doses of strategy than either alone (based on adult literature),
ibuprofen 10 mg/kg however, there is a real risk of toxicity due to dosing
per day and no more errors in children. If advising this strategy, a handout
than four doses of on dosing methods can help parents keep track of a
acetaminophen 15 mg/kg dosing schedule.
per day.
FOAMed link: Click here for a great blog post
reviewing the literature on the treatment of pediatric
fever by The Skeptics’ Guide to EM.
7
Case continued: On exam of this 12-month-old female, she appears tired

but non-toxic. Her vital signs are: a rectal temperature of 39.0°C, heart
rate of 125, and respiratory rate of 25. A thorough head-to-toe exam
reveals an erythematous and bulging left tympanic membrane.
Q: What is the normal change in heart rate and respiratory rate in

response to a fever?
A: Respiratory rate: Heart rate:

Increases by five Increases by 10
breaths per minute beats per minute
For every degree of fever above 38°C
So, in our 12-month-old girl:

•• Corrected HR = 125 – (10 x 1) = 115
•• Corrected RR = 25 – (5 x 1) = 20
Normal Pediatric Vital Signs by Age
Vital Sign Infant (0-12 mths) Child (1 -11 years) Pre-teen/Teen (12 yrs+)
Heart Rate 100 to 160 bpm 70 to 120 bpm 60 to 100 bpm
0 to 6 months 1 to 5 years
Resp Rate 30 to 60 bpm 20 to 30 bpm 12 to 18 bpm
(breaths per
min) 6 to 12 months 6 to 11 years
24 to 30 bpm 12 to 20 bpm
0 to 6 months 90 to 110 systolic / 110 to 135 systolic/

65 to 90 systolic 55 to 75 diastolic 65 to 85 diastolic
/45 to 65 mm Hg mmHg mmHg
Blood Pressure
6 to 12 months
80 to 100 systolic
/55 to 65 mm Hg
8
All ages
Rectal Temperature 36.6°C to 38°C (97.9°F to 100.4°F)
Tympanic Temperature 35.8°C to 38°C (96.4°F to 100.4°F)
Oral Temperature 35.5°C to 37.5°C (95.9°F to 99.5°F)
Axillary Temperature 34.7°C to 37.3°C (94.5°F to 99.1°F)
Case resolution: The child is observed in the ED and is treated with

ibuprofen 10 mg/kg po. She continues to look well, normal vital signs are
recorded, and she is tolerating oral fluids. You diagnose her with otitis
media and give the parents a prescription for amoxicillin. You give them
clear discharge instructions and advise them to follow up with their
primary-care physician.
Clinical Pearl:
If the child has abnormal vital signs after correcting for fever, have a high
degree of suspicion for dehydration, early compensated shock, or early
sepsis. Make sure you assess for perfusion and mentation, and ask about
urine output.
9
CASE 2:
URINARY TRACT INFECTION
An 18-month-old male is brought to your ED with four days of fever at
home between 38.0°C and 38.8°C. His parents say he has been fussier
than usual. He has no significant past medical history, his immunizations
are up to date, and there is no history of recent travel. He has been
drinking well at home. No infectious source is identified on history. On
exam, he is alert and non-toxic. Vital signs are normal except for an
oral temp of 38.2°C. On a thorough head-to-toe exam you do not find a
source of infection.
Q: This child has no source of infection that is readily

identifiable on history or physical. What is the difference
between fever without a source and fever of unknown origin?
A: Fever without a source: There is no identifiable source of fever after a

complete history and physical.
Fever of unknown origin: At least two to three weeks of fever without an

identifiable source after initial investigations. The most likely cause remains
infectious but other causes, such as malignancy and rheumatologic causes,
need to be considered.
Q: For children who present to the ED with fever without a

source, how likely are they to be suffering from an occult serious
bacterial infection?
A: A small proportion of these infants and young children will have

an occult bacterial infection, such as an occult urinary tract infection,
pneumonia, bacteremia or even early bacterial meningitis. These are
defined as SBIs, and occult UTI is the most common SBI, especially in the
first two years of life.
10
Q: Does immunizing children help prevent SBIs?
A: There is a very low rate of bacteremia in children with two or more doses
of the Haemophilus influenzae type b and pneumococcal conjugate vaccine.
In Canada, the Haemophilus vaccine is given at two, four, six, and 18 months,
and the pneumococcal vaccine is given at two, four, and12 months.
Ah-Ha!
For the child with a fever without a source, be sure to take a complete history
and to undress the child completely when performing a thorough physical exam.
Pay particular attention to the following points on history and physical exam:
History: Physical exam:
•• Duration of fever •• A careful assessment of the vital signs

•• Recent surgeries •• Behaviour and mental status
•• Underlying medical •• Meningeal signs and fontanelles
co-morbidities •• If the child is at an ambulatory stage
•• Previous infections of development, watch the child walk
•• Immunization status and look for a limp
•• A careful abdominal exam
•• A careful skin exam
•• A careful joint exam
Q: What are the five most common sources of fever in a child

without an obvious source for their fever after initial assessment?
A: These are defined by the LUCAS mnemonic:

•• Lungs
•• Urine
•• CNS
•• Abdomen
•• Skin
11

Pediatric Assessment of Appearance
Element Explanation
Tone Is he/she moving around or resisting examination

vigorously and spontaneously? Is there good muscle tone?
Interactability How alert is he/she? How readily does a person, object, or

sound distract or draw attention? Will he/she reach out,
grasp, and play with a toy or new object, such as a penlight
or tongue depressor?
Consolability Can he/she be consoled or comforted by the caregiver or

by the clinician?
Look/gaze Can he/she fix her gaze on the clinician’s or caregiver’s

face, or is there a “nobody home,” glassy-eyed stare?
Speech/cry Is his/her speech/cry strong, and spontaneous, or weak,

muffled, or hoarse?
Q: Is this 18-month-old male with a four-

day history of fever at risk for a UTI?
What are the risk factors for UTI in the

pediatric population?
A: Yes, he is at risk. The following are risk factors

for UTI:
•• Females < 24 months
•• All males < six months
•• Uncircumcised males < 24 months
•• Fever for more than two days
•• Fever > 39°C
•• History of previous UTI
12
Q: Does this 18-month-old male with a four-day history of fever need

testing for a UTI? How do you decide which children with fever to
test for a UTI?
A: Yes, this child does require testing for a UTI as he has multiple risk factors.
< Three months: Three to 24 > 24 months:

months:
Get a urine sample Check all girls; check
for all babies with Check all girls; check all symptomatic
fever without a uncircumcised boys if uncircumcised boys and
source ≥ one risk factor and circumcised boys with
circumcised boys if several symptoms of UTI
≥ two risk factors
Q: You tell the parents you would like to get a urine sample, and
they immediately express concern that they don’t want their child
to have a catheter placed. How do you get a urine sample in this
situation?
A: Your investigation of this child could begin with a urine bag specimen. In
general, the following principles apply when getting a urine sample.
< Two months: From two months Toilet trained:

until toilet trained:
Obtain urine sample Obtain a mid-
by catheterization and Bag urine is acceptable stream urine
send every sample to screen by microscopy; sample after
for a culture (as the if positive (i.e., > 10–20 adequate
urinalysis may be WBCs/hpf), a catheter cleaning of the
normal with a true sample is necessary. genitals
infection)
13
Clinical Pearl:
One study describes a safe, quick, and effective technique to obtaining a

midstream urine sample. Twenty-five minutes after feeding, simply hold the
baby upright, gently tap on the bladder for 30 seconds, then massage the
sacrum for 30 seconds. Both stimulation manoeuvres are repeated until
micturition starts.
Q: In what way can the urine dipstick be deceptive in children

who aren’t toilet trained?
A: The urine dipstick relies on leukocyte esterase and nitrites as an indirect

measure of pyruria and bacteriuria. The urine needs to be “incubating” in
the bladder for about four hours to become positive on the dipstick. So, the
child who isn’t toilet trained is urinating too often (more frequently than
every four hours) for the dipstick to become positive when an infection is
present.
Case continued: Let’s go back to our case of the 18-month-old

uncircumcised male. We end up getting a urine bag specimen. There are
40–50 WBCs/hpf, so we proceed to get a urine sample by catheterization
and send it for a urinalysis. The results come back with 30–40 WBCs/
hpf, suggestive of a UTI. As you are looking up the appropriate antibiotic
dose, you wonder about the child’s disposition.
Q: Which children with UTI need to be admitted to hospital?
A:
In general, children < two months of age with a UTI should be admitted
to hospital. Well-appearing children > two months old can usually be
discharged home on antibiotics with good follow-up, provided they do not
show any evidence of dehydration and have reliable caregivers.
14
Q: The parents ask whether their child has a problem with his
kidneys or bladder that predisposed him to a UTI. What sort of
follow-up should this 18-month-old male with a first-time UTI
have?
A: All children < two years of age with a first-time UTI should have an
outpatient ultrasound to look for vesico-ureteral reflux and structural
anomalies. A voiding cysto-urethrogram (VCUG) is no longer recommended
for children with a first-time UTI.
Q: What antibiotic options do you have for treating this child

with a UTI?
A: Treatment of pediatric UTI: Antibiotic options depend on local

antibiotic resistance patterns, however, in our experts’ catchment area
(Ottawa)
•• In hospital: IV ampicillin and gentamicin
•• Outpatient: Cephalexin for most, or cefixime for infants two to six
months old, or for those you are worried have a complicated UTI or
urinary tract abnormalities
Clinical Tools:
Click here for the Canadian

Paediatric Society
Guidelines on UTI in
children
15
CASE 3:
PNEUMONIA STRIKES
You are seeing a four-year-old female with a six-day history of a runny
nose, cough, and fatigue. She was brought to your ED because she
has had a fever for the past three days. She is otherwise healthy. On
examination, she appears tired but non-toxic. She has a temperature of
40.0°C, a respiratory rate of 30, a heart rate of 130, and a blood pressure
of 110/70. She has mild increased work of breathing.
Q: You are considering a diagnosis of pneumonia. What are the

factors on history, physical examination, and blood work that
make this diagnosis more likely?
A: History: Physical Exam:

•• Upper respiratory infection •• Increased work of breathing
for several days followed •• Tachypnea
by onset of fever
•• Fever for ≥ five days Investigations:
•• Cough for ≥ 10 days •• WBC count ≥ 20,000
•• Temperature ≥ 40°C
Clinical Pearl:
Carefully examine the patient for “quiet tachypnea.” Children with quiet
tachypnea will remain tachypneic after correcting the respiratory rate for the
fever (as described above)—this may indicate an underlying pneumonia.
16
Q: Other than the mild increased work of breathing, the rest of your
physical exam is normal. Does this four-year old girl warrant a chest
X-ray?
A: Yes, she should have a chest X-ray (see below) because she has multiple factors
that make the diagnosis of pneumonia more likely. Despite the fact that most
pediatric pneumonias are viral in origin, we are unable to accurately differentiate
between viral and bacterial causes based on the X-ray appearance alone. It is
therefore prudent to start antibiotics in all children who have an infiltrate on chest
X-ray that is consistent with pneumonia.
Q: Does this child require blood work and/or blood cultures? What are the
indications for blood work and blood cultures in pediatric fever without a
source?
A: A well-appearing, immunized child with a fever typically does not need blood work
or cultures. While C-reactive protein (CRP) and pro-calcitonin may be helpful in risk-
stratifying patients with fever without a source, this hasn’t become a standard of
practice, and the availability of pro-calcitonin in limited.
17
CASE 4:
THE FEBRILE NEONATE
A two-week-old female born at term is brought into your ED with a 24-
hour history of fever. No source can be identified on history or physical
exam. The child is alert but has a rectal temperature of 39.1°C.
Q: What sort of workup does this infant need?
A: This patient needs a full septic workup. Infants in the first month of life
have the highest rate of SBI out of any time in childhood, and therefore
they represent a high-risk group.
A full septic workup includes:

•• CBC
•• Blood cultures
•• Urinalysis collected by catheter
•• Urine culture
•• CSF sampling (send for: cell count, culture, Gram stain, protein, glucose,
and viral studies)
Q: This infant is started on IV antibiotics. Your resident asks you

whether the child requires acyclovir, in case the child has herpes
simplex encephalitis (HSV). What do you tell your resident?
A: If you suspect meningitis based on physical exam or lumbar puncture

results, start acyclovir. This is especially important in children < 14 days of
age, as the rate of HSV meningitis is highest in this age group. HSV can also
cause hepatitis and pneumonitis, so check for these if you are suspicious of
HSV meningitis.
18
CASE 5:
THE PARTIAL SEPTIC WORKUP
A two-month-old male born at 36 weeks is brought in with a 12-hour
history of fever. He is unvaccinated and he is circumcised. No focus is
identified on history or physical exam. He appears non-toxic and has a
rectal temperature of 38.6°C, and the rest of the vitals are normal.
Q: How do you correct for age when it comes to premature

infants who present with fever to the ED?
A: When calculating age for the purposes of infection, you should use the
chronological age; however, premature babies with a complex medical
history should be thought of as high risk.
Q: What sort of work-up does this two-month-old boy require?
A: This child will require at least a partial septic workup and then
be assessed regarding low-risk criteria to determine if any further
investigations are needed.
For children between 29–90 days of age, there are many criteria for the
work-up of fever without a source. Our experts recommend using the low-
risk criteria from the American Academy of Pediatrics. If these criteria are
met, the child has an approximate risk of 1.5% of developing an SBI. These
children may be safely discharged home if they have reliable parents and
follow-up is available within 24 hours.
Low-risk criteria (American Academy of Pediatrics): Clinical Tools:

•• No obvious source of infection
•• No complex past medical history Click here for a review
•• WBC count between 5–15,000 article of the American
•• Normal urinalysis (<10 WBCs/hpf) Academy of Pediatrics
•• Normal stool WBC count if they have diarrhea guidelines on fever without
•• Normal chest X-ray if there are respiratory symptoms a source.
19
Putting it All Together: Workup Decisions in Pediatric

Fever Without a Source
A full septic workup including LP is recommended for infants

younger than 28 days because they have the highest risk of SBI.
•• This includes routine blood work and culture, urinalysis and culture,
and lumbar puncture (cell count, protein, glucose, culture, Gram
stain and culture, and viral studies).
For infants ranging in age from 29 days to 90 days, use the

American Academy of Pediatrics low-risk criteria.
•• If they are well appearing, with no obvious source of infection, no
complex past medical history, normal laboratory criteria (WBC
count, normal urinalysis, and normal stool white count if diarrhea is
present), they can usually be sent home if they have reliable parents
and good availability for follow-up in 24 hours.
•• These infants have a rate of SBI of about 1.5% (usually UTI), so be
sure that urine is sent for culture in addition to urinalysis.
Comments?
Click here to leave a
comment or to listen to
this podcast.
20
KEY REFERENCES:
1. Baraff LJ. Management of infants and young children with fever without source. Pediatr Ann. 2008;
Oct;37(10):673-679.
2. Robinson JL, Finlay JC, Lang ME, Bortolussi R,. Urinary tract infection in infants and children:
Diagnosis and management. Paediatr Child Health. 2014; 19(6):315-319.
3. Shaikh N, Monroe NE, Lope J, et al. Does This Child Have a Urinary Tract Infection? JAMA, 2007;
298(24):2895-2904.
4. Subcommittee on Urinary Tract Infection, Steering Committee on Quality Improvement
and Management. Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and
Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months. Pediatrics. 2011;
128(3):595-610.
5. Wilkinson M, Bulloch B, Smith M. Prevalence of occult bacteremia in children aged 3 to 36 months
presenting to the emergency department with fever in the post pneumococcal conjugate vaccine
era. Acad Emerg Med. 2009; Mar;16(3):220-225.
21
CHAPTER 2:
SEPSIS & SEPTIC SHOCK
LISTEN TO THE PODCAST WITH SARAH REID AND GINA NETO HERE
Objectives
1. Recognize sepsis and septic shock in a pediatric patient
2. Understand the differences between the presentation, diagnosis, and
treatment of septic shock in children compared with adults
3. Review fluid management, antibiotic use, and vasopressor options in pediatric
sepsis and septic shock
22
CASE 1:
SICK OR NOT SICK, THAT IS THE QUESTION
A seven-day-old boy is brought to the ED with poor feeding and fewer
wet diapers for the past day. He was born via uncomplicated vaginal
delivery at term, and went home from the hospital with his mother
within 24 hours. He is exclusively breastfed and had been feeding
well up until last night, when he became disinterested in feeding.
On examination the child is sleeping but rouses easily. His vitals are:
temperature 37.5°C (rectal), heart rate 120, respiratory rate 40, and
oxygen saturation 96% on room air.
Q: As you hear this story, what other things are you thinking
about asking on history or looking for on physical exam?
A: Given the story, this is potentially quite a concerning situation. Pay close
attention to any change in a newborn’s normal pattern of behaviour, as
this can indicate a possible serious illness. In this age group the signs and
symptoms of sepsis can be quite vague and non-specific. Common signs of
neonatal sepsis that you should think to look for or ask about include:
•• Jaundice •• Vomiting
•• Hepatomegaly •• Abdominal distension
•• Poor feeding •• Diarrhea
23
Q: You make note of the newborn’s vital signs and start your
physical exam. You remember that the normal vital signs
for children depend on their age and you wonder if these are
normal. What are the normal vital signs in pediatric patients?
A:
Correcting Vital Signs for Fever

In febrile children, the heart rate increases by approximately 10 beats per
minute and respiratory rate increases by five breaths per minute for every
1°C or 1.8°F of fever over 38°C.
In this case, the only particular concern is that the young child is not
feeding as well as previously. Given that the rest of the history and a full
physical examination are normal, this child is likely not septic but perhaps
a bit dehydrated. Supplementation or strategies to aid feeding should be
discussed with the family. Given that the family is coping well, is reliable
and there are no other concerns, the child can be discharged home with
a plan for follow-up and clear discharge instructions to return if the child
continues a poor feeding pattern, develops a fever, or becomes lethargic or
irritable, or if the parents concerned.
24
CASE 2:
FROM BAD (AND ITCHY) TO WORSE
A seven-month-old girl has had

chicken pox for three days. She
develops a temperature of 38.7°C
and is crying constantly, and one of
the spots on her abdomen has an
area of increased redness around
it. She was seen at a walk-in clinic
and given antibiotics. However,
when she was brought home her
mother noted her to be limp and
unresponsive. She called 911.
Q: EMS had called you prior to their arrival at the ED with

a brief history. As you prepare for the patient’s arrival, you
remind yourself of the red flags, or risk factors, for sepsis in the
pediatric population. What do you listen for on history or look
for on physical exam?
A: It can be difficult to recognize sepsis because the signs and symptoms

can be so vague. However, there are a few red flags you should look for in
every potential case. These include:
1. Age younger than one year, and early adolescence (10–14 years); in
particular, children younger than one month old have a high risk
2. Unexplained tachycardia (after correction for fever)
3. Clinical signs of poor perfusion (prolonged capillary refill, lethargy,
irritability)
4. Conditions that predispose to sepsis: neuromuscular disease,
immunocompromised, respiratory conditions, cardiac disease
5. Recent surgery
25
In the ED, the patient’s vitals are: temperature 39.4°C, heart rate 168,
respiratory rate 44, blood pressure 70/35, and oxygen saturation 94%. The child
appears ill and is difficult to rouse. She is mottled and has a capillary refill of
five seconds.
Q: You pause during your examination of this child as you recognize

that she is sick and you begin to worry. What about her presentation is
worrying you?
A: This case describes an extremely unwell child. She is poorly perfused and
has an abnormal level of consciousness. Her heart rate is higher than would be
expected for her temperature, and her blood pressure is low for her age.
Case continued: As you make note of these things, you are recognizing the
signs of sepsis: tachycardia out of proportion to the fever, tachypnea, and poor
perfusion (capillary refill, lethargic, irritability).
Pitfall:
Suspicion of sepsis is a clinical In this case the child is frankly

judgment. Up to one-third of hypotensive, which can be a
patients with clinical sepsis do not pre-morbid sign in pediatric
fulfill the classic research diagnostic sepsis. Hypotension is a late sign
criteria. Severe sepsis is time-critical, of pediatric septic shock and
so have a high index of suspicion, imminent arrest. Do NOT wait for
and initiate sepsis investigations and hypotension to make the diagnosis
treatment until sepsis is excluded. of septic shock.
Q: You finish your physical examination and are anxious to start your
management and treatment. What is your first priority in managing
this patient?
A: The first priority in managing the critically ill child is obtaining vascular access to
start fluid resuscitation. Two peripheral intravenous lines should be placed. If you
cannot obtain IV access within the first 60 seconds, put in an intraosseous line.
26
Intraosseous Access
Intraosseous (IO) access can be used in all ages, even in awake patients.
Studies show that the pain from the IO comes more from the actual infusion
than from the insertion. To reduce pain, consider infiltrating lidocaine into
the bone prior to the infusion of fluids. The possibility of pain should not
cause hesitation in establishing IO access. The preferred IO sites in kids are
the proximal tibia, distal femur, and proximal humerus.
You can administer the same agents through an IO as an IV (fluids,

antibiotics, vasopressors).
Click here to listen to EM Cases Episode 61 for some great pearls and pitfalls on
intraosseous line placement.
Q: You secure a line and start to run your fluids. What

specifically are you going to run?
A: Fluids, typically a crystalloid such as normal saline or Ringer’s lactate,

are given in boluses of 20 cc/kg, repeated up to a total of 60 cc/kg within
the first hour, as long as there are no signs of hepatomegaly, crackles in
the lungs, or sonographic evidence of pulmonary edema, while monitoring
the effects. For younger children (< two years of age) this is done by filling a
30–60 cc syringe with saline and manually bolusing. For older children, use
a level 1 infuser. Adequate volume resuscitation is critical to prevent the
child from crashing post-intubation or with positive-pressure ventilation.
Caution:
Intubation and positive-pressure ventilation may increase intrathoracic

pressure and decrease venous return, thus worsening shock. It is important
to adequately volume resuscitate these kids before intubation to prevent
them from crashing.
27
Clinical Pearl:
A rapid and effective way to administer fluid boluses in children younger than
two years of age is to fill large syringes with normal saline and push 20 cc/kg
boluses as needed to a maximum of 60 cc/kg.
Q: You know that early administration of antibiotics is essential in

managing sepsis and septic shock. What antibiotic options do you have?
A: For this patient, a reasonable choice of initial antibiotic therapy would be ceftriaxone
75 mg/kg.
Empiric Antibiotic Treatment by Age:
Children > 28 days of age who are normal hosts:

•• Vancomycin (15 mg/kg, maximum 1–2 g, for the initial dose) in areas with
high MRSA prevalence
•• Plus cefotaxime (100 mg/kg, maximum 2 g, for the initial dose) OR
ceftriaxone (75 mg/kg, maximum 2 g, for the initial dose)
•• Consider adding an aminoglycoside (e.g., gentamicin) for possible
GU source, and/or piperacillin with tazobactam, clindamycin, or
metronidazole for possible GI source
Infants zero to 28 days of age:

•• Vancomycin (15 mg/kg for the initial dose) in areas with high MRSA
prevalence
•• Plus cefotaxime (50 mg/kg for the initial dose)
•• Plus gentamicin (2.5 mg/kg for the initial dose)
•• Plus ampicillin (50 mg/kg for the initial dose)
•• Add acyclovir (20 mg/kg per dose) for suspicion of HSV infection
Note that local resistance patterns may dictate different antibiotic regimens.
28
Q: The nurse has now also successfully drawn blood and asks what
investigations you would like to order.
A: General investigations for the child Hypocalcemia is commonly seen in

with sepsis are blood work for CBC, critically ill children with sepsis, and it
electrolytes, glucose, kidney function, is recommended to treat hypocalcemia
blood gas, blood cultures, LFTs, ionized even in the absence of clinical
calcium, and lactate. Hypoglycemia manifestations such as seizures and
is relatively common and should be cardiac arrhythmias.
identified early by bedside capillary
blood analysis and then treated. In the Treat with calcium gluconate 10%
undifferentiated septic patient, urine 0.5-1 ml/kg up to 20 ml slowly over five
cultures are commonly done to identify minutes (calcium chloride 10% 0.1-0.2
a possible source. Clinical history guides ml/kg up to 10 ml can also be used, but
imaging such as chest X-ray. should be given through a central line).
Clinical Pearl:
Check capillary glucose early and treat hypoglycemia with D10W 5 cc/kg.
Q: Your patient received a total of 60 cc/kg of crystalloid fluids as well as an

empiric dose of antibiotics. Her heart rate is now 120, blood pressure 80/50,
respiratory rate 30. Her extremities are cool and she is mottled with a delayed
capillary refill. What is your next move?
A: She is now in fluid-refractory shock. If a patient has received a full

60 cc/kg of crystalloids and is still manifesting clinical signs of septic shock, it is
time to consider inotropes/vasopressors. While the choice of initial vasopressor
has traditionally been dopamine, current evidence suggests that epinephrine for
“cold shock” or norepinephrine for “warm shock” are better choices. In this case,
and in most children suffering from septic shock, the type of shock is cold shock,
as apposed to warm shock that affects the vast majority of adults suffering from
septic shock.
29
Inotropes in Fluid-Refractory Shock
•• Warm shock as seen in most adults in septic shock (warm extremities,

flash capillary refill): norepinephrine 0.1-2 mcg/kg/min IV/IO infusion,
titrate to desired effect
•• Cold shock as seen in most children in septic shock (cool extremities,
delayed capillary refill): epinephrine 0.1-1 mcg/kg/min IV/IO infusion,
titrate to desired effect
Pitfall
A common pitfall in the management of fluid-refractory septic shock is to

delay the initiation of vasopressors when there is no central line in place
yet. The lack of a central line should not delay the initiation of vasopressors,
which can initially run through a peripheral IV or IO line.
Q: What about securing the airway for this child in septic shock? When
would you consider endotracheal intubation for pediatric patients in septic
shock?
A: Consider early intubation in fluid-refractory septic shock (after three boluses of 20

ml/kg IV/IO NS) or in any compromised airway.
Infants or neonates with severe sepsis are more likely to require early intubation.
Again, intubation and mechanical ventilation increase intrathoracic pressure, which
reduces venous return and leads to worsening shock. Therefore, fluid resuscitation
must be done first.
Case continued: You start epinephrine and call your colleagues in the pediatric ICU
to tell them about the patient and ask for their assistance. They thank you for your
good work and arrive in the ED shortly to continue care of our young girl.
30
CASE 3:
SHOCKED
A nine-year-old girl is brought to the ED with a history of vomiting and diarrhea.
Her heart rate is 140, respiratory rate 36, blood pressure 77/40, and temperature
37.8°C, and she is lethargic and difficult to rouse. She is treated with aggressive fluid
resuscitation, after which her hemodynamic status does not improve.
Q: You start to worry when her clinical status does not improve with
aggressive fluids. What quick test is vital to obtain at this point?
A: Up to 25% of children with septic shock will have adrenal insufficiency. Many
of these patients will have concomitant hypoglycemia, so always check the serum
glucose in septic children. Extremes in blood glucose in sepsis are associated with
higher mortality in children.
Clinical Pearl:
ABC + DEFG = ABC and DON’T EVER FORGET GLUCOSE
31
Q: Her capillary glucose is 1.2 and she is treated with D10W 5 cc/kg IV.
You then also start an epinephrine infusion, but her hemodynamic
status does not improve much. What do you think is causing this, and
what else could you try at this point?
A: This patient is in catecholamine-resistant shock. Consideration should be

given to administering systemic corticosteroids.
Clinical Pearl:
When a child is fluid refractory and catecholamine resistant in shock,

think of adrenal insufficiency. Again, up to 25% of kids with sepsis will
have adrenal insufficiency either from prior steroid use, from the cause
of sepsis itself or from primary adrenal insufficiency. Treatment is
hydrocortisone 2 mg/kg IV.
Q: Great! You start systemic corticosteroids

and continue your resuscitation. To stay
on top of the resuscitation of this child,
you must attempt to achieve certain goals.
What markers of a successful sepsis
resuscitation are you looking for?
A: You are watching for the following:
•• Capillary refill < two seconds

•• Normal blood pressure
•• Normal pulses with no differential between
central and peripheral pulses
•• Warm extremities Click here to listen to Dr. Reid’s Best
•• Urine output > 1 ml/kg/hr Case Ever for more helpful tips on
•• Normal mental status sepsis and shock.
•• Normal lactate
32
Putting it All Together: An Example of an Algorithm for
Pediatric Septic Shock
Children's Hospital of Eastern Ontario Algorithm for Septic Shock: Note that dopamine, although
included in this algorithm, is no longer recommended as the initial vasopressor of choice in pediatric septic shock.
•• Assess ABCs, cardiorespiratory monitoring

•• O2 10 L NRB
•• Establish IV access x 2 (IO access if failed two attempts)
•• Investigations (See Severe Sepsis PPO)
•• Bedside glucose
•• Blood work (CBC, blood C&S, electrolytes, VBG, urea, Cr,
glucose, lactate, PT/PTT, ALT, blood cross-match)
•• CXR
•• Urinalysis (consider indwelling urinary catheter)
10 MIN •• First bolus: NS 20 ml/kg given IV push rapidly over 5-10 min.
•• Give antibiotics (see Severe Sepsis PPO)
•• Reassess HR, RR, BP, perfusion, O2 sat and if remain abnormal:

20 MIN
•• Second bolus: NS 20 ml/kg given IV push rapidly over 5-10 min.
•• Reassess HR, RR, BP, perfusion, O2 sat and if abnormal:
30 MIN •• Third bolus: NS 20 ml/kg given IV push rapidly over 5-10 min.
•• Consider PICU consult and prepare dopamine infusion
•• Reassess HR, RR, BP, perfusion, O2 sat, and if abnormal:

40 MIN •• Fluid-refractory shock
•• Start dopamine 10 mcg/kg/min
•• Consult PICU and consider hydrocortisone 2 mg/kg
Consider intubation: ketamine 1 mg/kg; rocuronium 1 mg/kg; succinylcholine

1-2 mg/kg; or atropine 0.01-0.02 mg/kg
33
KEY REFERENCES:
1. Weiss SL, Parker B, Bullock ME, et al. Defining pediatric sepsis by different criteria: discrepancies
in populations and implications for clinical practice. Pediatr Crit Care Med. 2012; July;13(4):e219-26.
2. Dieckmann R, Brownstein D, Gausche-Hill M (eds): Pediatric Education for Prehospital Professionals.
Sudbury, Mass, Jones & Bartlett, American Academy of Pediatrics, 2000, pp 43-45.
3. Davies P, Maconochie I. The relationship between body temperature, heart rate and respiratory
rate in children. Emerg Med J. 2009 Sep;26(9):641-3. doi: 10.1136/emj.2008.061598.
4. Van de Voorde P1, Emerson B, Gomez B, et al. Paediatric community-acquired septic shock:
results from the REPEM network study. 2013, Eur J Pediatr. 2013; May;172(5):667-74.
5. Dellinger RP. Surviving Sepsis Campaign: International Guidelines for Management of Severe
Sepsis and Septic Shock: 2012. Intensive Care Med. 2013; 39:165-228.
6. Sá RA, Melo CL, Dantas RB, Delfim LV. Vascular access through the intraosseous route in pediatric
emergencies. Rev Bras Ter Intensiva. 2012; 24(4):407-414.
7. Weiss SL, Fitzgerald JC, Balamuth F, et al. Delayed antimicrobial therapy increases mortality and
organ dysfunction duration in pediatric sepsis. Crit Care Med. 2014; 42(11):2409-17
8. Shekerdemian L, Bohn D. Cardiovascular effects of mechanical ventilation. Arch Dis Child. 1999;
80:475-480.
9. Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric-neonatal septic shock by
community physicians is associated with improved outcome. Pediatrics. 2003; Oct;112(4):793-9.
10. Butt W. Septic shock. Pediatr Clin North Am. 2001; Jun;48(3):601-25.
11. Gaines NN, Patel B, Williams EA, Cruz AT. Etiologies of septic shock in a pediatric emergency
department population. Pediatr Infect Dis J. 2012; Nov;31(11):1203-5.
12. Paul R, Melendez E, Stack A, et al. Improving adherence to PALS septic shock guidelines. Pediatrics.
2014; 133:(5)1358-1366.
13. Aneja R, Carcillo JA. What is the rationale for hydrocortisone treatment in children with infection-
related adrenal insufficiency and septic shock? Arch Dis Child. 2007; Feb;92(2):165-9
Comments?
this podcast.
34
CHAPTER 3:
PAIN MANAGEMENT
LISTEN TO THE PODCAST WITH SAMINA ALI AND ANTHONY CROCCO HERE
Objectives
1. Develop a systematic approach to assessing pain in the pediatric patient
2. Develop a step-wise approach to treating pediatric patient pain in the emergency
department
3. Develop an approach to communicating with and treating a pediatric patient who is
anxious about a sensitive physical exam or invasive procedure
4. Develop an appreciation of moderate to severe pain treatment modalities in a
pediatric patient (e.g., IM, IN, IH)
5. Develop an approach to using different therapeutic agents (acetaminophen,
ibuprofen, morphine, fentanyl, ketamine, nitrous oxide)
35
CASE 1:
PEDIATRIC PAIN ASSESSMENT & TREATMENT
APPROACH
A five-year-old boy presents to your emergency
department with a 24-hour history of peri-umbilical
abdominal pain, vomiting, and low-grade fever. At
triage he is given ibuprophen 10 mg/kg po for the
pain. When you examine him, he appears to be in
a significant amount of pain, and has RLQ rebound
tenderness and guarding.
You make the patient NPO, order an IV, give ondansetron for the vomiting, and
organize an ultrasound to confirm your suspicion for appendicitis.
Q: Why is effective ED pain management in children important, and what are

the consequences of untreated pain in children?
A: Consequences of untreated and undertreated pediatric pain:
Short-term detrimental effects: Long-term detrimental effects:

1. Extended procedure duration 1. Infant pain may adversely change
2. Delay in diagnosis neural pain processing
3. Increased length of stay 2. Avoidance and heightened sensitivity
4. Parental concern and dissatisfaction to future medical care
5. Slower surgical healing 3. Fear and increased pain experienced
6. Emotional trauma and suffering with future health-care evaluation
Developing a systematic, team-based approach to assessing and managing

pediatric pain in a busy emergency department will save time overall.
36
Clinical Pearl:
Pitfall:
Most clinicians underestimate Use of clinical assessment tools can

the extent of pain in a pediatric be expedited and standardized by
patient, and do not reassess having a pocket or electronic copy
their therapeutic interventions with the treating physician, on the
frequently enough to determine chart, or completed and recorded
effectiveness. by triage.
Q: What are the best evidence-based tools to use for pain

assessment for this five-year old boy, and in older and younger
pediatric patients?
A:
< Four years old: FLACC Scale
37
Four to Eight Years Old: Faces Pain Scale–Revised
The Faces Pain Scale has been validated in different ethnic populations. This may
make it more generalizable than the Wong-Baker FACES Pain Rating Scale due
to differing cultural practices and implications with crying; i.e., not all cultural
groups express pain and suffering with tears.
> Eight Years Old: Visual Analog Scale
Pitfall:
Vital signs do not correlate with pain severity or improvement in pain scores.
Assuming minimal pain because the vital signs are normal is a common pitfall.
38
Q: What can be done to treat the pain of this five-year-old boy with suspected
appendicitis in a timely manner?
A:
1. Triage is a great place to start. Nurse-driven protocols may expedite pediatric pain
identification and management. Alternatively child life specialists, if available, can assist
in this process.
2. Many Canadian hospitals employ oral acetaminophen or ibuprophen triage-initiated
pain protocols. Some hospitals employ physician-approved intranasal fentanyl and oral
opioids at triage.
Your comments?
Pitfall:
One study found that the average What is the strategy in your ED
wait time for pain treatment of non- to improve the timeliness of pain
musculoskeletal presentations to be treatment?
approximately two hours.
Q: What analgesic options would you recommend for this five-year-old boy with
non-musculoskeletal pain?
A: Treatment of undifferentiated abdominal pain with analgesics does not lead to more
complications or negatively affect the accuracy of the physical exam. This is a common myth
that has been debunked in the literature and that delays appropriate pain management.
Graded Analgesic Options for Pain Anticipated to Last Hours
Mild–Moderate Pain
1. Ibuprofen 10 mg/kg Q6h

2. Acetaminophen 15 mg/kg Q4h
3. Ibuprophen + acetaminophen
39
The combination of ibuprofen +

acetaminophen can be an effective pain Ibuprofen has been shown
management tool in the emergency to be superior to and have
department for pediatric patients. In adults, a longer duration of action
it has been shown to be superior to either than acetaminophen
one alone. While it has widespread adoption for mild–moderate pain
and anecdotally positive results, it has not anticipated to last hours.
been studied adequately in children.
Q: You give this five-year-old boy ibuprofen 10 mg/kg po and

acetaminophen 15 mg/kg po, and an hour later the nurse calls to tell you
the boy is scoring high on the Faces Pain Scale–Revised. What’s your
next pain management move?
A:
Moderate-Severe Pain
1. Ibuprofen +/- acetaminophen AND

2. Morphine oral suspension OR 0.2-0.5 mg/kg PO (max 15 mg) Q4-6H
3. Morphine IV* 0.1 mg/kg IV push titrated to response
• IV morphine is recommended for severe pain that is expected to last for hours to
days, especially for patients who have been deemed NPO.
• IV morphine is effective in both musculoskeletal and non-musculoskeletal pain
when ibuprofen +/- acetaminophen is not providing adequate pain control.
• IV morphine should be given as an IV push (not in a minibag) to facilitate
frequent reassessment and titration to effect.
• Physicians who may be hesitant to treat the pediatric population with opioids,
or who do not encounter this population frequently, may begin with morphine
0.05 mg/kg IV push. It is essential to reassess the patient’s pain in 10 minutes to
titrate appropriately.
40
Caution:
An oxygen saturation monitor is recommended for children receiving multiple

doses of opioids (i.e., with the second dose) to monitor for respiratory
depression.
Case continued: You get the ultrasound report back that shows no signs
of appendicitis, and when you re-examine the boy he scores low on
the Faces Pain Scale–Revised and is no longer tender to palpation. You
decide to send the patient home and to have him return for a repeat
ultrasound the next day.
Q: What analgesic medications will you suggest to his parents

for home?
A: Step-Wise Ladder Approach to Outpatient Pain Management
41
Caution:
Outpatient use of acetaminophen concurrently with ibuprofen may

lead to dosing errors and inadvertent overdose. Therefore, it should be
considered only for children with parents who:
•• Are reliable
•• Have been counselled thoroughly
•• Show an appreciation of medication scheduling
•• Will commit to documenting the drug dosing at home
Q: How will you council the parents of

this five-year-old boy regarding the
opioid analgesic prescription that you
Clinical Pearl:
may give them?
Give the first oral dose in the

A: Often there is considerable parental
emergency department prior to
concern for children being discharged with an
discharge. This allows for a better
opioid prescription. Pre-emptive counselling of
transition from IV to PO pain
parents may include:
coverage. It also provides some
•• Providing the evidence for and the efficacy
observation time for an opioid-
of opioid analgesia in children
naive patient receiving it orally.
•• Explaining that opioid addiction is rare in
children who are being treated for pain
•• Reviewing important side effects with
patients, including respiratory distress,
drowsiness, and constipation
•• Having the parents commit to
documenting medication regimen
•• Having the parents commit to keeping
opioid medication (along with all other
medications in the home) in a safe place
away from children
42
Pitfall:
Codeine is a pro-drug that

gets converted into morphine.
Some people are ultra-rapid
metabolizers of codeine, and
receive a huge surge of morphine
systemically along with its adverse
effects. Its use in the pediatric
population and in breastfeeding
mothers should be avoided. It has For another illustration of the dangers
been linked to adverse effects, of codeine with ultra-rapid metabolizers
including death (see the story of listen to Dr. Anthony Crocco’s Best Case
Tariq and Rani Jamieson). Ever: The Neonatal Lazy Feeder.
CASE 2:
PEDIATRIC PAIN ASSESSMENT &
TREATMENT APPROACH
A three-year-old girl is sent to your ED from one of your community
pediatricians with a four-day history of fever and maculo-papular rash.
She fulfills the criteria for Kawasaki disease. The pediatrician asks you to
place an IV in the ED so that IV IG can be given.
You get a call from the nurse telling you that they’re having a difficult
time getting the IV. When you enter the room, the child looks terrified
and is not co-operating.
43
Q: What non-medical techniques will you use to minimize

anxiety and pain in this child?
A: Examples of age-specific distraction techniques:
Young children:
•• Favourite
blanket/toys
•• Bubbles
•• Books
•• Audiotapes
•• Videos/movies
Toddlers and older children: Older children/

•• Music has been shown to minimize the teenagers:
pain and anxiety associated with painful •• Behavioural
procedures in children. Simply using a techniques such
parent’s smartphone or tablet device to play as relaxation,
a child’s favourite music is a low-cost, simple biofeedback,
distraction technique. breathing
•• Guided visual imagery may be of •• Physical elements
particular benefit to children, as they are such as heat, cold,
generally accepting of the idea of fantasy positioning
and suggestion. The dissociative effects of
ketamine in particular make it an ideal agent
for the adjunctive use of guided imagery.
44
Q: What if you need to place an IV in a four-month-old? What

non-medical techniques have been shown to be effective?
A:
1. Breastfeeding or breast milk
•• Doesn’t eliminate the pain, but it helps temper it
•• Not established for repeated painful procedures
•• If not available, use glucose/sucrose
2. Oral sucrose
•• Reduces signs of distress in babies < six months of
age
•• Most effective in infants (< 28 days of age)
•• Improved efficacy in combination with non-nutritive
sucking via pacifier
3. Warming the patient
•• Use an infant warmer or warming blanket
Clinical Pearl: Clinical Pearl:
For effective pain reduction associated

Pain management techniques
with venipuncture in infants, give 2 ml
such as distraction and sucrose
of sucrose 22% or more, two minutes
can increase procedure
before the procedure on the anterior
success, such as IV placement
tongue.
and lumbar puncture, due to
increased patient comfort and
If you do not have oral sucrose solution,
co-operation.
you can prepare your own by diluting
D50 with saline to get D25.
Q: What pharmacologic techniques would you use to decrease

pain associated with IV placement?
45
A: Topical analgesic options for venipuncture:
Specific agents may be considered for the following situations:

1. Lancing an abscess: Consider vapocolant spray for its very short
duration and avoiding pain of injecting local anesthetic.
2. Lumbar puncture: Consider using liposomal lidocaine, as it has been
studied specifically with lumbar punctures and showed some benefit.
3. Venipuncture: Consider starting with amethocaine, as it has a short
onset of action and has been shown to be superior to EMLA.
Clinical Pearl:
Evidence-based approach to distraction and Once non-pharmacologic

pain management in infants/children: options are employed, consider
1. Music one of the following for
2. Breastfeeding venipuncture/lumbar puncture:
3. Sucrose solution 1. Amethocaine 4%
4. Non-nutritive sucking (also to augment 2. Liposomal lidocaine 4%
sucrose solution) 3. J-tip with buffered lidocaine
5. Warm environment
46
CASE 3:
SENSITIVE EXAMINATIONS
AND PROCEDURES
A six-year-old girl comes in after falling off her
bicycle with a straddle injury. Her mother reports
that she saw blood in the underwear. The child
refuses to disrobe despite your reassurance.
Q: What communication techniques may be used to help relieve

anxiety in this child?
A: Anxiety is an important component of and contributor to the pediatric

pain experience, especially with sensitive exams such as a genital or
perineal exam. Some useful techniques include:
•• Ensure parents are in the room; consider examining the patient in
their parent’s arms if the patient is young and it will not hinder the
assessment
•• Reassure the child in a reasonable way without making false
statements (e.g., “We will take a break if it gets to be too much,” as
opposed to “We will stop if it gets to be too much”)
•• Consider lowering yourself physically to the patient’s eye level or lower
•• Explain the procedure in age-appropriate terms
•• Give the patient a realistic choice to empower them (e.g., “I have to look
down there; would you rather me do this while you are lying on the
bed or sitting on Mom’s lap?”)
•• Procedural sedation may be considered if verbal techniques fail
Q: What non-pharmacologic treatment options would you use to

minimize pain in this patient?
A: Options include:
•• Allowing position of comfort
•• Applying ice packs
•• Wrapping bruising (if present)
47
Q: What pharmacologic modalities would you use in this patient?
A: Considerations for patient treatment may include pain and/or anxiety. If

pharmacologic agents are chosen, they should reflect the treatment goals.
Midazolam
•• A small percentage of patients get a paradoxical reaction of increased anxiety
and agitation.
•• Reaction to this benzodiazepine is variable, and as such should be considered
second line.
Nitrous oxide (NO)

•• NO is a relatively weak dissociative anesthetic gas that has several properties
including opioid receptor agonism and NMDA and glutamate receptor
antagonism. Therefore, it provides mild–moderate anxiolysis, analgesia, and
amnesia (a great combination).
•• Adverse events seen in 0.03% include vomitting, dizziness, and euphoria/
dysphoria, rendering it safe.
•• Most hospital protocols do not necessitate fasting prior to use.
•• There is no residual effect.
•• It has been found to be comparable to IV ketamine for fracture reductions.
Ketamine may cause altered perception and confusion. It should be avoided in

sensitive situations such as genital/perineal exams and suspected abuse cases.
48
CASE 4:
MUSCULOSKELETAL PAIN
A 10-year-old girl comes in after a FOOSH in the playground. She appears very anxious
when you examine her. Her X-ray shows a distal radius fracture requiring reduction. She
has not received any analgesia. She has no IV established.
Q: Given her painful injury, to bridge the gap until the sedation starts, what
analgesics would you recommend for this patient?
A:
Intranasal fentanyl:
Clinical Pearl:
•• Similar onset of action to
intravenous opiates •• Intranasal limitations: nasal secretions/
•• Painless administration congestion
•• A general rule of thumb is that twice •• Do NOT dilute the drugs
the IV dose is needed •• Use both nares (rather than one) for
•• Less risk for respiratory depression volumes > 0.3 ml (1.5 ml+ each nare)
with the appropriate dosing, in the
rare event necessitating a reversal
agent, such as IN naloxone
Key Reference:
•• If oral medication is also a
therapeutic option, consider Intranasal ketamine used in children
administering oral pain medication three to 13 years of age with an isolated
at the same time as the nasal limb injury and moderate to severe pain
medication, to time the oral was shown to have similar pain reduction
therapeutic effect onset with the IN when compared with intranasal fentanyl.
dose decline
49
CASE 5:
LACERATION
CONSIDERATIONS
Lidocaine epinephrine
A three-year-old boy has fallen while tetracaine (LET) gel has been
re-enacting a Superman scene. You find a shown to decrease pain in
simple laceration on his forehead. children with lacerations that
are treated with skin adhesive.
Q: How can you minimize pain and
emotional trauma for this child?
A: Options include: Clinical Pearl:

•• Using tissue adhesive, if possible
•• Using lidocaine epinephrine tetracaine If using tissue adhesive:
(LET) prior to using the tissue adhesive
•• Using distraction principles mentioned •• Explain that the adhesive
above will get warm and may
“sting”
•• Keep adhesive out of the
laceration (it is meant to
maintain skin together, not
Some pediatric emergency departments fill the defect)
employ nurse-initiated LET application at triage •• Consider using LET prior to
for all children with lacerations, regardless of lidocaine infiltration
the method of laceration closure used. This
may expedite assessment, management, and
discharge.
Comments?
Click here to leave a comment or

to listen to this podcast.
50
KEY REFERENCES:
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children. Arch Pediatr Adolesc Med. 1998; Feb;152(2):147-149.
2. Kim MK, Strait RT, Sato TT, Hennes HM. A randomized clinical trial of analgesia in children with acute
abdominal pain. Acad Emerg Med. 2002; Apr;9(4):281-287.
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Apr;31(2):165-72.
4. Page GG. Are There Long-Term Consequences of Pain in Newborn or Very Young Infants? J Perinat Educ.
2004 Summer; 13(3):10-17. doi: 10.1624/105812404X1725
5. Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The FLACC: a behavioral scale for scoring postoperative
pain in young children. Pediatr Nurs. 1997; 23(3):293-7.
6. Hicks CL. von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The Faces Pain Scale–Revised: toward a
common metric in pediatric pain measurement. Pain. 2001; Aug;93(2):173-183.
7. Wong DL, Baker CM. Pain in children: comparison of assessment scales. Pediatr Nurs. 1998; 14(1):9-17.
8. Bandstra NF, Skinner L, Leblanc C, et al. (2008). The role of child life in pediatric pain management: a survey
of child life specialists. J Pain. 2008; Apr;9(4):320-9.
9. Ali S, Drendel AL, Kircher J, Beno S. Pain management of musculoskeletal injuries in children: Current state
and future directions. Pediatr Emerg Care. 2010; Jul;26(7):518-524,
10. Drendel AL, Kelly BK, Ali S. Pain Assessment for Children: Overcoming Challenges and Optimizing Care.
Pediatric Emergency Care. 27(8):773-81, 2011. PMID: 21822093.
11. Zempsky WT, Cravero JP. American Academy of Pediatrics Committee on Pediatric Emergency Medicine and
Section on Anesthesiology and Pain Medicine. Relief of pain and anxiety in pediatric patients in emergency
medical systems. Pediatrics. 2004; Nov;114(5):1348-56.
12. Kircher J, Drendel AL, Newton AS, Dulai S, Vandermeer B, Ali S. Pediatric musculoskeletal pain in the
emergency department: a medical record review of practice variation. CJEM. 2014; Nov;16(6):449-57.
13. Poonai N, Paskar D, Konrad SL, et al. Opioid analgesia for acute abdominal pain in children: A systematic
review and meta-analysis. Acad Emerg Med. 2014 Nov;21(11):1183-92. doi: 10.1111/acem.12509.
14. McGaw T, Raborn W, Grace M. Analgesics in pediatric dental surgery: relative efficacy of aluminum
ibuprofen suspension and acetaminophen elixir. ASDC J Dent Child. 1987;54(2):106-109.
15. Clark E, Plint AC, Correll R, Gaboury I, Passi B. A randomized, controlled trial of acetaminophen, ibuprofen,
and codeine for acute pain relief in children with musculoskeletal trauma. Pediatrics. 2007; Mar;119(3):460-7.
16. Kramer LC, Richards PA, Thompson AM, Harper DP, Fairchok MP. Alternating antipyretics: antipyretic
efficacy of acetaminophen versus acetaminophen alternated with ibuprofen in children. Clin Pediatr (Phila).
2008; Nov;47(9):907-11.
17. Poonai N, Bhullar G, Lin K, et al. Oral administration of morphine versus ibuprofen to manage postfracture
pain in children: a randomized trial. CMAJ. 2014; Dec 9;186(18):1358-63. doi: 10.1503/cmaj.140907. Epub
2014 Oct 27.
51
18. Kleiber C, Harper DC. Effects of distraction on children’s pain and distress during medical procedures: a
meta-analysis. Nurs Res. 1999; 48(1), 44-9.
19. Shah PS, Herbozo C, Aliwalas LL, Shah VS. Breastfeeding or breast milk for procedural pain in neonates.
Cochrane Database Syst Rev. 2012; Dec 12;12:CD004950.
20. Curtis SJ, Jou H, Ali S, Vandermeer B, Klassen T. A randomized controlled trial of sucrose and/or pacifier
as analgesia for infants receiving venipuncture in a pediatric emergency department. BMC Pediatr. 2007;
7(1):27.
21. Stevens B, Yamada J, Ohlsson A. (2004). Sucrose for analgesia in newborn infants undergoing painful
procedures. Cochrane Database Syst Rev. 2004; (3):CD001069.
22. Zempsky WT. Pharmacologic Approaches for Reducing Venous Access Pain in Children. Pediatrics. 2008;
Nov;122 Supple 3:S140-53.
23. Jimenez N, Bradford H, Seidel KD, Sousa M, Lynn AM. A Comparison of a needle-free injection system for
local anesthesia versus EMLA® for intravenous catheter insertion in the pediatric patient. Anesth Analg.
2006; Feb;102(2), 411-4.
24. Spanos S, Booth R, Koenig H, Sikes K, Gracely E, Kim IK. Jet injection of 1% buffered lidocaine versus topical
ELA-Max for anesthesia before peripheral intravenous catheterization in children: A randomized controlled
trial. Pediatr Emerg Care, 2008; Aug;24(8), 511-5.
25. Zier JL, Liu M. Safety of High-Concentration Nitrous Oxide by Nasal Mask for Pediatric Procedural Sedation.
Pediatr Emerg Care. 2011; Dec;27(12): 1107-12.
26. National Institute for Health and Clinical Excellence (NICE). Sedation in Children and Young People. London:
Royal College of Physicians (UK). NICE Clinical Guidelines. 2010; Dec. 30; no. 112.
27. Borland M, Jacobs I, King B, O’Brien D. A randomized controlled trial comparing intranasal fentanyl to
intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med.
2007; Mar;49(3):335-40.
28. Rickard C, O’Meara P, McGrail M, Garner D, McLean A, Le Lievre P, A randomized controlled trial of
intranasal fentanyl vs intravenous morphine for analgesia in the prehospital setting. Am J Emerg Med. 2007;
Oct;25(8):911-7.
29. Graudins A, Meek R, Egerton-Warburton D, Oakley E, Seith R. The PICHFORK (Pain in Children Fentanyl or
Ketamine) trial: a randomized controlled trial comparing intranasal ketamine and fentanyl for the relief of
moderate to severe pain in children with limb injuries. Ann Emerg Med. 2015 Mar;65(3):248-254.e1.
30. Singer AJ, Stark MJ. Pretreatment of Lacerations with Lidocaine, Epinephrine, and Tetracaine at Triage: A
Randomized Double-blind Trial. Acad Emerg Med. 2000; Jul;7(7):751-6.
31. Harman S, Zemek R, Duncan MJ, Ying Y, Petrich W. Efficacy and pain control with topical lidocaine-
epinephrine-tetracaine during laceration repair with tissue adhesive in children: a randomized controlled
trial. CMAJ. 2013; 185(13):E629-34.
52
CHAPTER 4:
HEAD INJURY
LISTEN TO THE PODCAST WITH RAHIM VALANI AND JENNIFER RILEY HERE
Objectives
1. Outline the classification of pediatric traumatic head injuries
2. Review and compare the PECARN and CATCH clinical decision
instruments for minor head injury
3. Explore the role of skull X-rays in children with minor head injury
4. Review Return to Sport guidelines after pediatric head injury
5. Review elevated ICP management in a critically ill child with traumatic
brain injury
53
CASE 1:
MINOR HEAD INJURY
A mother presents to the emergency department with her nine-month-
old male infant who fell down four steps onto a concrete sidewalk while
in a stroller that had overturned. She reports that he cried immediately,
did not vomit, and did not have a seizure. The infant is otherwise
healthy, with no previous head injuries or significant medical history.
On examination, he is alert and crying. His heart rate is 132 bpm, blood
pressure is 85/50, respiratory rate is 26, temperature is 36.5oC, and
oxygen saturation is 99% on room air. His GCS is 15 with equal and
reactive pupils. Neck range of motion is normal. He is moving all limbs
normally. Full exposure of the infant reveals a 3 cm boggy occipital
hematoma. There are no signs of basal skull fracture, and no signs of
injury of the chest, abdomen, back, or limbs.
Q: How would you classify this head injury—trivial, minor,

moderate, or severe?
Trivial head injury: Minor head injury: Moderate–severe

head injury:
•• GCS 15 •• Eighty-five per cent of
•• No loss of non-trivial head injury •• GCS ≤ 13 or
consciousness, low •• GCS 14–15 deteriorating GCS
energy mechanism •• Loss of consciousness, •• Penetrating head
•• Small frontal amnesia, or confusion injury
hematoma, no other •• Disorientation •• Focal neurologic
signs of traumatic •• Other symptoms/signs findings
brain injury (TBI) (vomiting, headache) •• Late seizure (not
•• Older than one year •• Impact seizure impact)
•• Known child abuse
54
Q: Does this infant require a CT scan of the head to rule out

significant TBI?
A: In general, the incidence of clinically significant TBI requiring intervention

in children with minor head injury is low. While the yield of CT in minor
head injury for any intracranial lesion is approximately 5%, neurosurgical
lesions occur in only 0.5%.
Proportion of all-comers with minor head injury who will require

intervention:
•• Normal mental status: 0.8%
•• AND no signs of skull fracture: 0.5%
•• AND no history of vomiting: 0.2%
•• AND no history of persistent headache: 0%
Select populations have very low risk of TBI:

•• Isolated vomiting
•• Isolated LOC
•• Isolated amnesia
Radiation considerations in pediatric head injury imaging
The fastest-growing group of patients getting CT scans is pediatric patients,

with an estimated 600,000 CT scans done annually on children under the
age of 15 years in the United States. The lifetime risk of cancer due to CT
scans (which have been estimated in the literature using projection models
based on atomic bomb survivors) is about one case of cancer for every
1,000 people who are scanned. For head CTs in children in particular, a
retrospective cohort study assessing leukemia and brain tumour risk from
pediatric head CT estimated that one case of leukemia and one brain
tumour will result from every 10,000 children scanned. Radiation exposure
in infancy may effect IQ later in life.
55
Pediatric Emergency Care Applied Research

Network (PECARN) Study:
Clinical decision instruments for pediatric head injury

Based on a PECARN study, the validated predictors of clinically important TBI
in children younger than two years include:
1. Altered mental status

2. Non-frontal scalp hematoma
3. Loss of consciousness for at least five seconds
4. Severe mechanism of injury
5. Palpable skull fracture
6. Not acting normally, according to the parent
The risk of clinically important TBI in a child with none of these six predictors
was found to be 0.02%. In prospective validation, both the sensitivity and
negative predictive value for the detection of TBI was 100% for children
younger than two years old.
For children with one or more of these predictors, either CT scan or

observation may be appropriate, depending on several factors, such as
physician experience, with a lower threshold to image children with multiple,
more severe, or worsening signs or symptoms. Clinicians should not use these
criteria to trigger a scan in a child whom they otherwise would not image.
Extra caution is still advisable in children younger than three months, in whom
clinical evaluation is less reliable.
The PECARN group also performed a secondary analysis of a prospective

observational cohort of children with minor head injury and a GCS of 14–15
who had isolated vomiting
For the CATCH study clinical prediction instrument and comparison to the PECARN
rule, see Case 2.
56
Q: What is the significance of a scalp hematoma in an otherwise

asymptomatic head-injured infant?
A: Among asymptomatic head-injured infants, the risk of skull fracture and

associated intracranial injury is correlated with scalp hematoma size > 2cm
and location (non-frontal).
Q: Is there any role for a skull X-ray in ruling out clinically

significant TBI?
A: Background: Eleven per cent of children under the age of two years will
sustain a skull fracture associated with head trauma. Fifteen to 30 per cent
of these will have TBI; therefore, in a child under the age of two years, a
skull fracture is a predictor of TBI. Children with skull fractures require a
head CT to rule out significant intracranial injuries.
While there is little evidence for the role of skull X-rays in ruling out
clinically significant TBI , in practice locations where CT is not readily
available, consider a skull X-ray for children under the age of two years
who present with a significant scalp hematoma with no other signs of TBI
as a screening test for skull fracture. Ensure a radiologist’s interpretation,
as emergency physicians’ interpretations of pediatric skull X-rays have
been shown to have poor accuracy for detecting skull fractures.
57
Clinical Pearls in Pediatric Minor Head Injury:
1. Isolated loss of consciousness or amnesia: In one study of 2,043

children with minor head injury, isolated LOC, and/or amnesia
with no other signs or symptoms, none had a positive CT and none
required surgery.
2. Persistent irritability is always a worrisome sign in a head-injured

child under the age of two years.
3. Isolated vomiting is rarely associated with significant TBI. Some

experts believe that post-head-injury vomiting may be more related
to a personal history of recurrent vomiting; on the other hand,
persistent vomiting associated with other symptoms of TBI does
have a significant positive predictive value for TBI.
Click here for an analysis of studies of isolated vomiting in pediatric

minor head injury.
58
CASE 2:
MODERATE HEAD INJURY
A six-year-old boy was walking with his family on a windy evening. As
they passed a construction site, a truck driver opened a large metal gate,
which swung out of control and hit the child in the head. The child was
thrown back approximately six feet and landed on the back of his head
on the edge of a cement curb. There was a loss of consciousness of three
to five minutes, and upon awakening the child was confused and had
two episodes of vomiting. He arrives in the emergency department with
paramedics. On further questioning he is amnestic; however, he does recall
walking with his parents prior to the event. In the ED, he is perseverating.
On examination:
Heart rate is 110 bpm, blood pressure is 118/60, respiratory rate is 20,
temperature is 36.5°C, and oxygen saturation is 98% on room air.
A: Patent
B: Breathing spontaneously, good air entry bilaterally
C: Cap refill three seconds, pedal pulses present
D: Pupils are equal and reactive at 4 mm, GSC is 13
There is a large hematoma to the forehead as well as a large occipital

hematoma. There are no signs of basal skull fracture. Abdomen is soft
and non-distended, bowel sounds are present. The pelvis is stable.
Extremities are normal. There is no tenderness over the spine. Neurological
examination is normal, aside from the GCS of 13.
The patient is otherwise healthy; all of his immunizations are up to date.
Q: Does this child require a CT scan?
A: As you know from Case 1, the PECARN study helps us to decide whom not
to CT scan. In addition, we can use the CATCH study to help us decide whom
to CT scan.
59
CATCH Study:
The Canadian Assessment of Tomography for Childhood Head

Injury (CATCH)
Head CT is required only for minor head injury patients with any
one of these findings:
•• Minor head injury is defined as injury within the past 24 hours
associated with witnessed loss of consciousness, definite
amnesia, witnessed disorientation, persistent vomiting, or
persistent irritability (in a child younger than 2 years of age) with
a GCS of 13–15.
•• High risk (100% sensitive for neurological intervention):

1. GCS score < 15 at two hours post-impact
2. Suspected skull penetration or depressed fracture
3. Worsening headache on history
4. Irritability on exam
•• Medium risk (98% sensitive for any lesion on CT scan):

1. Any sign of basilar skull fracture
2. Large, boggy scalp hematoma
3. Dangerous mechanism, such as:
a) Fall from height ≥ 3 feet or ≥ five stairs
b) Motor vehicle–related
c) Fall from bicycle with no helmet
A prospective study comparing the sensitivity and specificity of the PECARN and CATCH rules,
as well as a third set of rules called the CHALICE, found the PECARN rules to be the most
sensitive (100%), while the CATCH rules were found to be 91% sensitive. This is to be expected,
as the PECARN rules are meant to rule out the need for a CT in minor injuries, as opposed to
rule in the need for one. The CHALICE rule was identified as the least sensitive.
60
Q: What are the signs of basilar skull fracture?
A:
•• Hemotympanum
•• Periorbital ecchymosis (raccoon eyes)
•• Mastoid bone ecchymosis (Battle’s sign)
•• Cerebrospinal fluid leak from the nose or ears (otorrhea/rhinorrhea)
Signs of basilar skull fracture
Q: What are the key differences between the adult CT Head Rule
and the CATCH rule?
A: The CATCH rule does not include vomiting and amnesia, but instead
includes irritability in a child younger than two years old, or worsening
headache in the older child, and the presence of a large boggy scalp
hematoma.
61
Q: How long should a child with mild or moderate head injury

who is deemed unsuitable for a CT scan be observed in the
emergency department?
A: If the child has any of the following, then guidelines suggest either a
four- to six-hour observation period, or going straight to CT scan: history of
loss of consciousness, amnesia, confusion, lethargy or persistent vomiting,
severe or persistent headache, or immediate post-traumatic seizure.
Q: What discharge instructions should be given to children with

minor head injuries or moderate head injuries who are deemed
suitable to go home?
A:
•• The first six hours post-injury are referred to as the “red zone,” and the
subsequent 24 hours are the “yellow zone.”
•• Waking up the patient every two hours is probably not necessary (and
if the clinician believes the patient to be high risk, he/she should be
kept in the department longer).
•• Partially waking up the patient once during the night to assure

reasonable behaviour might be reasonable, especially if within the “red
zone” time.
62
Q: When can the patient return to sport?
A: A variety of guidelines exists to help answer this question, but every

athlete needs an individual approach to prevent second-impact syndrome.
A reasonable general guideline includes refraining from all activity until one
week post-resolution of post-concussive symptoms (headache, amnesia,
dizziness), and then using a step-wise approach: mild exertion to increase
heart rate, sport-related activity with no contact, progressive return to full
practice, and then return to game situations. If symptoms develop at any of
these stages, go back to the previous stage and consult the primary care-
giver of the patient. See CPS summary on evaluation of concussion and Return
to Play guidelines here.
EM Cases cross-link: For Dr. Joel Yaphe’s review of the guidelines

“Concussions and their consequences: current diagnosis management
and prevention” (published in CMAJ in 2013) from Whistler’s Update in EM
Conference 2014, go here.
Q: How do pediatric head injuries differ from adult head

injuries?
A:
•• Children’s skull sutures are not closed yet, so their skulls tend to be
more distensible than those of adults. This leads to less TBI after head
trauma with comparable mechanism of injury.
•• Children sustain fewer mass lesions and fewer hemorrhagic
contusions.
•• Children sustain more diffuse brain swelling and can “talk and
deteriorate” with edema alone.
•• Children sustain more diffuse axonal injury.
•• Children sustain more hypoxia.
•• Children have more seizures.
63
CASE 3:
MAJOR HEAD INJURY
A five-year-old girl was the front-seat passenger in a
motor vehicle crash. The child was wearing her seat belt,
but no airbags were deployed. The collision occurred
when the driver lost control of the car on the highway,
hitting the concrete divider on the left side of the vehicle.
It was unknown whether the child lost consciousness.
At the scene, the child was confused and combative.
Unfortunately, the driver of the vehicle did not survive.
On examination, the vitals are as follows:
Heart rate is 100 bpm, blood pressure is 130/90 mmHg, respiratory rate
is 24, temperature is 36.6°C, and oxygen saturation is 98% on oxygen.
A: Patent
B: Breathing, good air entry bilaterally
C: Cap refill three seconds, pedal pulses present
D: Pupils are equal and reactive at 4 mm, GSC is 7 (E3V2M2);
no focal neurological findings.
There are multiple abrasions, a contusion over one eye, a lip laceration,
and a chipped tooth. There is a seat belt bruise on the abdomen, and
the abdomen is tender. There are stellate lacerations of 3 cm and
a hematoma over the right parietal region, with no palpable skull
depression. There are no signs of basilar skull fracture. In addition, there
is an open, complex fracture of the right ankle.
As you are examining the child, her conditions worsen: The GSC drops to
3, while the heart rate and blood pressure remain steady at 95 bpm and
140/95, respectively. The right pupil remains at 4 mm while the left pupil
is now 7 mm.
64
Q: Assuming that you want to intubate this patient and send her
for an immediate CT, how would you best sedate the child for
intubation and CT scanning?
A: Although the literature is sparse and controversial for the effectiveness

of pre-medication to blunt the effects of intubation on raised intracranial
pressure (ICP) in the pediatric population, consider pre-medication of
fentanyl or lidocaine as part of rapid-sequence intubation (RSI) algorithm.
It is important to note that these medications need to be given a full two
to three minutes before intubation to be effective, therefore they are not
suitable in a “crash” intubation situation.
The induction agent should aim to prevent a drop in blood pressure, given
that CPP = MAP – ICP (cerebral perfusion pressure equals mean arterial
pressure minus intracranial pressure). Etomidate probably remains the
agent of choice. However, there is evidence that ketamine is a safe and
suitable alternative for sedation in TBI, with recent systematic reviews failing
to demonstrate increased ICP after ketamine use. Ketamine may offer
neuroprotective effects secondary to its effects on NMDA receptor activity.
For sedation to enable CT scanning in the young pediatric patient, agents

that decrease blood pressure should be avoided. Ketamine is an ideal agent
for this purpose, as it has been shown not to raise intracranial pressure,
it is an effective analgesic and amnesic, it may be neuroprotective, and it
does not lower the blood pressure. Ketamine can be given intravenously,
intramuscularly, or by the intranasal route.
Expert Tip:
To enable CT scan sedation, keep the very young child awake as long as
possible before going to the CT scanner, and perform the CT scan when
the child falls asleep. Feeding the child and then performing the CT scan
during the post-feed nap can also be an effective way to enable sedation.
65
Q: What signs should I be watching for if I am worried about

elevated ICP?
A: Elevated ICP occurs in up to 80% of children with TBI. Clinical clues of

increased ICP include worsening headache, visual or neurologic complaints,
and persistent vomiting, as well as abnormal pupillary reflexes, decreasing
level of awareness, lateralizing features, and Cushing’s triad.
Q: How do I manage elevated ICP?
A: Methods for acutely decreasing ICP in the emergency department

include elevation of the head of the bed 30 degrees, with the head mid-
line, intravenous mannitol or hypertonic saline administration and
hyperventilation, which is used only as a temporizing measure in a patient
who shows evidence of brain herniation or who is being imminently
transferred to the operating room (target pCO2 is 30–35 mmHg).
Mannitol works by creating an intravascular osmotic pull, hence decreasing

blood viscosity and increasing intravascular osmolarity. This helps to decrease
brain edema by setting up an osmotic gradient across an intact blood-brain
barrier (BBB). Mannitol is dosed as a bolus of 0.25-1 g/kg.
Q: Is there an alternative to mannitol for the treatment of elevated

ICP?
A: Hypertonic saline (3%) was shown to be more effective than mannitol

in lowering raised ICP in one meta-analysis of adult studies, and is
recommended especially if the patient is hypotensive as it has no osmotic
diuretic effect. It is given as a bolus of 2-6 ml/kg, followed by an infusion of
0.1-1 ml/kg/hr.
FOAMed link: For a detailed analysis of elevated ICP Comments?

management, see Dr. Scott Weingart’s suggestions on EMCrit.
this podcast.
66
KEY REFERENCES:
1. 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. 2009;
374(9696):1160-70.
2. Greenes DS, Schutzman SA. Clinical significance of scalp abnormalities in asymptomatic head-
injured infants. Pediatr Emerg Care. 2001; Apr;17(2):88-92.
3. Hall P, Adami HO, Trichopoulos D, et al. Effect of low doses of ionising radiation in infancy
on cognitive function in adulthood: Swedish population based cohort study. BMJ. 2004; Jan;
328(7430):19.
4. Brenner DJ, Hall EJ. Current concepts - Computed tomography - An increasing source of radiation
exposure. New Engl J Med. 2007; Nov;357(22):2277-84.
5. Palchak MJ, Holmes JF, Vance CW, et al. Does an isolated history of loss of consciousness
or amnesia predict brain injuries in children after blunt head trauma? Pediatrics. 2004;
June;113(6):e507-13.
6. Osmond MH, Klassen TP, Wells GA, et al. CATCH: a clinical decision rule for the use of computed
tomography in children with minor head injury. CMAJ. 2010; Mar;182(4):341-8.
7. Easter JS, Bakes K, Dhaliwal J, Miller M, Caruso E, Haukoos JS. Comparison of PECARN, CATCH, and
CHALICE rules for children with minor head injury: a prospective cohort study. Ann Emerg Med.
2014; Aug;64(2):145-52.
8. Tator CH. Concussions and their consequences: current diagnosis management, and prevention..
CMAJ. 2013; Aug;185(11):975-979.
9. Filanovsky Y, Miller P, Kao J. Myth: Ketamine should not be used as an induction agent for
intubation in patients with head injury. CJEM. 2010; Mar;12(2):154-7.
10. Dayan PS, Holmes JF, Atabaki S, et al. Traumatic Brain Injury Study Group of the Pediatric
Emergency Care Applied Research Network (PECARN). Association of traumatic brain injuries with
vomiting in children with blunt head trauma. Ann Emerg Med. 2014; Jun;63(6):657-65.
11. Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in childhood and
subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet. 2012; Aug
4;380(9840):499-505.
12. Farrell CA, Canadian Paediatric Society Acute Care Committee. Management of the paediatric
patient with acute head trauma. Paediatr Child Health. 2013; 18(5):253-8.
13. Kamel H, Navi BB, Nakagawa K, Hemphill JC 3rd, Ko NU. Hypertonic saline versus mannitol for the
treatment of elevated intracranial pressure: a meta-analysis of randomized clinical trials. Crit Care
Med. 2011; Mar;39(3):554-9.
67
CHAPTER 5:
PEDIATRIC PROCEDURAL
SEDATION
LISTEN TO THE PODCAST WITH AMY DRENDEL HERE
Objectives
1. Develop an approach to pediatric procedural sedation for fracture reduction, dislocation, and
other painful procedures
2. Develop an approach to pediatric procedural sedation for patients requiring anxiolytics for
minor procedures and imaging
3. Develop an approach to pediatric procedural sedation for patients requiring a lumbar puncture
4. Understand the important pharmacological properties, benefits, and precautions of the
various medications for pediatric procedural sedation (ketamine, propofol, fentanyl,etomidate,
nitrous oxide, midazolam)
68
CASE 1:
PROCEDURAL SEDATION FOR
PAINFUL PROCEDURES
A 10-year-old morbidly obese boy presents to
the emergency department after a FOOSH in the
playground. After a full history, exam, and X-ray,
you diagnose him with a distal radius fracture,
requiring reduction. The boy appears very
anxious.
Q: The child has not received any

medications at home or at triage. It will take
about an hour to assemble the team for the
procedural sedation. What analgesics would
you consider giving in the meantime?
A: A great starting choice for a patient in this

scenario would be intranasal (IN) fentanyl. Fentanyl
is an effective analgesic and works quickly, with an
onset of action of about three minutes (a faster
onset compared with intravenous opiates), and
negates needing an IV.
Fentanyl IN is given at a dose of

1-2 mcg/kg with a maximum dose of
100 mcg. Use a mucosal atomizing
device to deliver this dose intranasally.
69
Clinical Pearl: Using Intranasal Fentanyl
•• Use the most concentrated formulation and do not dilute it

•• Use both nostrils for volumes > 0.3 ml to double the absorptive
surface and reduce runoff
•• Consider administering oral pain medication concurrently for
continued pain management after the fentanyl has worn off
•• Respiratory depression is rare with correct dosing; however,
naloxone is also effective intranasally if needed as a reversal agent
For evidence, explanations and tips on Intranasal medications and

medication delivery, click here to visit intranasal.net.
Q: As you are preparing the medication, the parents appear to be

worried and ask you whether needles are required. How would
you involve the parents in your procedural sedation plan?
A: The EM literature has shown over and over that families prefer staying
at the bedside for procedures. Parents’ use of distraction techniques with
music or videos from smartphones or tablets, and even helping out in
the procedure, can improve parental satisfaction and decrease the child’s
anxiety. So, generally speaking, it’s a good idea to have Mom or Dad at
the bedside helping out. However, we’ve all been in the situation when
Mom or Dad starts freaking out during the procedure—and usually we can
anticipate which family members will react this way—so for those folks, you
may elect to ask them to step out of the room during the procedure.
You may also consider using other distraction techniques as outlined in this
chapter.
70
Q: You decide to have the parents nearby soothing the child and distracting
him with their games on their smartphone. Now it’s time to prepare for the
sedation. What do you consider in preparing to mitigate any potential risks
during the procedure?
A: Always do a full assessment, paying attention to any prior procedural sedations

and their success. Include any past medical history, allergies, and any current illnesses,
as these may affect your choice of medication. In the past medical history, be sure to
screen specifically for asthma, viral respiratory infections and obstructive sleep apnea
as these are important risk factors for complications. Also conduct a thorough focused
examination of the child and, in particular, the child’s airway and oral cavity.
Have a procedural sedation tray or procedure tray nearby, and have the child on a
cardiac monitor with frequent vital signs, including a pulse oximeter. If it is available,
use capnography as it has been shown to pick up respiratory depression earlier than
an oxygen saturation probe. Ensure you have at least one dedicated nurse during the
procedure. Also, have all of your age-appropriate airway equipment (including suction
and oxygen) on hand in case of complications.
Pitfall:
Pediatric patients are at a higher risk of airway obstruction due to anatomical
factors such as large occiput and tongue, and narrower, more pliant airways.
Patients younger than three months of age should be sent to anesthesiology due
to more complex neurodevelopmental considerations with sedation.
71
Q: As part of your history, you ask the parents when the child
last had anything to eat or drink, and they tell you that he ate a
hamburger two hours prior. Are you safe to go ahead with the
sedation, or do you need to wait another few hours?
A: It is helpful to know when the patient last ate, but the literature does
not support mandatory fasting to prevent complications of aspiration
in procedural sedation. A large study addressing this question found no
difference in adverse events among children who had been fasting two,
four, six, or eight hours. A conservative approach based on the American
Society of Anesthesiologists’ fasting guidelines would be to wait three to
four hours after their last meal, but there is no indication to wait if you
urgently need to perform a procedure.
Q: Now that you have a good grasp on the patient’s history and
physical exam and you have prepared all of your equipment, you
consider the options available to you for sedation of the patient.
What are your options for sedating this patient?
A: You have a variety of options that each have their own strengths and
risks. Consider each in relation to your specific clinical scenario. Different
agents may influence the risk of emesis. For example, ketamine is the most
commonly used medication, but may increase the risk of emesis. Nitrous
oxide also has similar risk of emesis, while propofol may have a decreased
risk but may not be suitable for younger or unstable patients. Consider
adding an antiemetic, such as ondansetron, prior to the sedation. There is
evidence to support the use of ondansetron in conjunction with ketamine
to reduce the risk of emesis (NNT= 9). While the addition of midazolam
to ketamine may reduce the likelihood of emesis, it increases the risk of
respiratory depression and will prolong the recovery time.
Ketamine has become the most common agent for pediatric procedural
sedation. It provides the desired trifecta of analegesia, sedation, and
amnesia in a single agent.
72
Ketamine Sedation
Pitfall:
Using ketamine in children younger than three months of age has an increased
rate of respiratory complications, and animal studies have implicated NMDA
antagonists as a cause of apoptosis and neurodegeneration in developing brains.
73
IV ketamine is generally preferred over IM ketamine. IM ketamine has a

longer recovery period and a higher rate of emesis, and is difficult to titrate
if more sedation is needed.
Clinical Pearl:
Rapid push dose of IV ketamine at Benzodiazepines are

0.8 mg/kg as an alternative to slow IV push useful for treating the
ketamine has been evaluated by Chinta rare emergency reactions
et al. in a pilot study of 20 children. The that are associated with
preliminary data are encouraging, as the ketamine, but they do not
success of adequate sedation and adverse decreased the likelihood
reactions seen were comparable to the of an emergency reaction
standard dose and slow IV push while occurring. Furthermore, co-
having a shorter recovery time. However, administration of midazolam
rapid-push dose IV ketamine cannot be increases the risk of
recommended for pediatric procedural respiratory complications,
sedation until a large, validated RCT has even though the risk of emesis
shown definitive results. is reduced.
Q: What other medication options besides ketamine would you

consider?
A:
Etomidate
Etomidate has been shown to be safe for Etomidate
procedural sedation in the pediatric population.
Its benefits include a favourable hemodynamic Etomidate dosing for
profile and short duration of action. Consider how pediatric procedural
much time you anticipate the procedure to last, as sedation: 0.1 to 0.2 mg/kg
etomidate is best suited for short procedures. slow IV push
74
Propofol Propofol
The risks of respiratory depression with propofol
are much higher than with ketamine. In addition, Propofol dosing for
propofol does not have any analgesic properties, pediatric procedural
so it is recommended that it be combined with an sedation: 0.5 to1 mg/kg
analgesic such as fentanyl. slow IV push
Nitrous oxide (NO)

Nitrous oxide is a weak dissociative anesthetic and it gives a rapid, reliable change in
depth of analgesia and sedation with a rapid recovery. Effective analgesia can often be
obtained with local lidocaine or regional nerve blocks, but we still require a calm and
sedated child to complete the procedure. Nitrous oxide is especially well-suited for the
patient who requires more anxiolysis than pain control. Examples of procedures where
nitrous oxide would be a reasonable option include genital lacerations and reduction of
forearm fractures.
Nitrous Oxide (NO)
Dosing NO: Nitrous oxide is delivered by Studies have

nebulizer via a gas system, usually 50% NO shown that nitrous
as a baseline dose. Some machines will allow oxide sedation, in
you to adjust the percentage of nitrous the conjunction with a
patient is inhaling so you can titrate the hematoma block for
depth of sedation. You can add an opioid or forearm fractures,
benzodiazepine to achieve a deeper sedation. was just as effective
as IV ketamine and
Time of onset: approximately three to five midazolam, and had a
minutes faster recovery time.
Recovery: approximately three to five minutes
75
Q: One of your senior EM doc colleagues pokes his head in the room
and asks, “Why don’t you just use good old fentanyl and midazolam?
I’ve been using that for conscious sedation on kids for 30 years.” Are
fentanyl and midazolam a good choice for procedural sedation?
A: Fentanyl + midazolam
A combination of fentanyl and midazolam used to be a popular cocktail
for procedural sedation. This combination is no longer recommended as
it has been associated with a high incidence of adverse events, including
respiratory depression and apnea.
Q: Then your student asks, “What about ‘ketofol’—the combination of

ketamine and propofol?”
A: Using ketamine and propofol in combination has a theoretical decreased risk of

adverse events due to decreased dosing of each agent. “Ketofol” has been shown to
have a shorter recovery time compared with either agent alone. Some experts argue
that in the event the patient has an allergic reaction, one doesn’t know which agent
caused the reaction, and therefore neither agent can be used again in that patient,
leaving fewer option available the next time they require sedation. In combination,
the recommended doses for ketofol are ketamine 0.5 mg/kg followed by propofol
0.5-1 mg/kg, or both drugs mixed into the same syringe and given at once together.
Q: You begin the procedural sedation and the patient begins to de-
saturate. What are the risk factors for a failed sedation (hypoxia, apnea)?
A:
Clinical Pearl:
•• Active upper respiratory tract infection

•• > ASA class 2+
•• Obesity or sleep apnea, or history of snoring
•• Older than seven years
76
Q: With some supplemental oxygen and repositioning, the patient improves.

The parents come back in the room and ask you how long they have to wait
until they can go home. After uncomplicated procedural sedations, how long
should you continue to observe the patient for?
A: The length of observation time depends on the agents used and the patient’s reaction to
the medications. When the patient has returned to their normal developmentally appropriate
motor, cognitive, and social functions; when they can tolerate PO; if they have a reliable
monitoring plan at home (and the family is comfortable with this plan), they are safe to go
home.

Dosing Pocket Guide
77
CASE 2:
PROCEDURAL SEDATION FOR SHORT,
NON-PAINFUL PROCEDURES
An 11 month-old boy falls out his mother’s arms as she trips down the stairs. She
saw him hit his head. He had a loss of consciousness of one minute and vomited
several times after the event. He presents with a GCS of 13 and no signs of basal
skull fracture, and point-of-care ultrasound shows no skull fracture. He is agitated,
but appears to be suffering from a minimal amount of pain.
Q: After a full clinical assessment with consideration of the PECARN

clinical decision aid (see Chapter 4 on Head Injury), you decide to send
the child for a CT scan of his head. You are concerned he will not be able
to tolerate the scan and feel that he needs to be sedated. What strategies
can you use in this scenario?
A: Non-painful short procedures can begin with distraction techniques (see Chapter 3
on Pain Management). If distraction techniques are ineffective, intranasal midazolam
is recommended as the first-line therapy for sedation. If IN midazolam is not
available, oral midazolam is recommended.
Midazolam Dosing
Intranasal dose: 0.3 mg/kg (max 10 mg); time of onset: seven to 10 minutes
Oral dose: 0.7 mg/kg (max 20 mg); time of onset: 15–20 minutes
Pitfall:
Before administering midazolam, consider the recovery time and that it may
cloud your physical and neurological assessments of the patient. Perform a
good neurological exam before the sedation, or else you won’t be able to give
the neurosurgical team an accurate report if they are consulted!
78
CASE 3:
PROCEDURAL SEDATION FOR LUMBAR
PUNCTURE
A three-year-old male infant presents to the ED with a temperature of
39.7°C, heart rate of 190, and mottled skin. There is no travel history
and no identifiable source of infection; however, he is unimmunized.
You begin your management with a full septic workup, IV fluids, and
broad-spectrum antibiotics.
Q: You are concerned that this patient could have meningitis,

and you want to do a lumbar puncture. Is there anything you
can do to make your patient more comfortable to help him
tolerate the procedure?
A: First, consider having the parents stay in the room to console the
patient, if they are able to and they understand the procedure. Family
presence has not been shown to increase the miss rates of the lumbar
puncture.
An important intervention used to maximize the chances of success

with lumbar puncture is adequate local pain control. Anesthetising the
skin with topical lidocaine (LMX 4%) can be helpful in this regard without
having to resort to the discomfort of injected lidocaine. LMX has an
onset within 30 minutes with reliable anesthetic effect at about seven
minutes, and was shown to increase success of lumbar puncture in two
prospective observational studies of 428 and 1,474 patients.
Local pain control, along with distraction techniques, can often obviate
the need for systemic sedation. For young infants who cannot be
distracted, sucrose has been shown to be an effective sedative.
Sucrose can often achieve the desired level of sedation such that other
less safe medications are not required in infants younger than three
months of age.
79
Medications of Choice for Sedation for Lumbar Puncture
< Six months old: Sucrose
Six months to five years: IN midazolam

(or oral midazolam if IN is not available)
> Five years: Inhaled nitrous oxide or midazolam
For more on local puncture site management, go to Chapter 3: Pain

Management.
FOAMed link: Click here for the TREKK Summary and Recommendations for
procedural sedation.
Comments?
Click here to leave a comment

or to listen to this podcast.
KEY REFERENCES:
1. http://www.intranasal.net/PainControl/INpaincontroldefault.htm#Introduction
2. Borland M, Jacobs I, King B, O’Brien D. A randomized controlled trial comparing intranasal
fentanyl to intravenous morphine for managing acute pain in children in the emergency
department. Ann Emerg Med. 2007; Mar;49(3):335-40.
3. Agrawal D, Manzi SF, Gupta R, Krauss B. Preprocedural fasting state and adverse events in
children undergoing procedural sedation and analgesia in a pediatric emergency department.
Ann Emerg Med. 2003; Nov;42(5):636-646.
4. Evered L, Bhatt M. TREKK Bottom Line Recommendations: Procedural Sedation. 2015. http://
cme02.med.umanitoba.ca/assets/trekk/assets/attachments/69/original/bottom-line-summary-
procedural-sedation.pdf?1435343376.
5. Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet. 2006;
Mar;367(9512):766-80.
80
6. Chinta SS, Schrock CR, McAllister JD, Jaffe DM, Liu J, Kennedy RM. Rapid administration technique
of ketamine for pediatric forearm fracture reduction: a dose-finding study. Ann Emerg Med. 2015;
Jun;65(6):640-648.
7. Cote CJ, Wilson S, the Work Group on Sedation. Guidelines for monitoring and management
of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an
update. Pediatrics. 2006; Dec;118(6):2587-2602.  
8. Krauss BS, Brauss BA, Green SM. Procedural Sedation and Analgesia in Children. N Engl J Med.
2014; 370:e23.  
9. Foster D, Upton R, Christrup L, Popper L. Pharmacokinetics and pharmacodynamics of intranasal
versus intravenous fentanyl in patients with pain after oral surgery. Annals of Pharmacotherapy,
2008; 42(10):1380-1387.
10. Wathen JE, Roback MG, Mackenzie T, Bothner JP. (2000). Does midazolam alter the clinical effects
of intravenous ketamine sedation in children? A double-blind, randomized, controlled, emergency
department trial. Ann Emerg Med. 2000; Dec;36(6):579-588.
11. Langston WT, Wathen JE, Roback MG, Bajaj L. Effect of ondansetron on the incidence of vomiting
associated with ketamine sedation in children: a double-blind, randomized, placebo-controlled
trial. Ann Emerg Med. 2008; Jul;52(1):30-34.
12. Shah A, Mosdossy G, McLeod S, Lehnhardt K, Peddle M, Rieder M. A blinded, randomized
controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in
children. Ann Emerg Med. 2011; May;57(5), 425-433.
13. Grunwell JR, McCracken C, Fortenberry J, Stockwell J, Kamat P. Risk factors leading to failed
procedural sedation in children outside the operating room. Pediatr Emerg Care. 2014; Jun;30(6),
381-387.
14. Langston WT, Wathen JE, Roback MG, Bajaj L. Effect of ondansetron on the incidence of vomiting
associated with ketamine sedation in children: a double-blind, randomized, placebo-controlled
trial. Ann Emerg Med. 2008; Jul;52(1):30-34
15. Andolfatto G, Willman E. A prospective case series of pediatric procedural sedation and analgesia
in the emergency department using single-syringe ketamine-propofol combination (ketofol). Acad
Emerg Med. 2010; Feb;17(2):194-201.
16. David H, Shipp J. A randomized controlled trial of ketamine/propofol versus propofol alone for
emergency department procedural sedation. Ann Emerg Med. 2011;57:435-441
17. Deasy C, Babl FE. Intravenous vs intramuscular ketamine for pediatric procedural sedation by
emergency medicine specialists: a review. Paediatr Anaesth. 2010; Sep;20(9):787-96.
18. Nigrovic LE, McQueen AA, Neuman,MI. Lumbar puncture success rate is not influenced by family-
member presence. Pediatrics. 2007; Oct;120(4), e777-782.
81
CHAPTER 6:
ORTHOPEDIC INJURIES
LISTEN TO THE PODCAST WITH SANJAY MEHTA AND JONATHAN PIRIE HERE
Objectives
1. Develop an approach to managing a child with an acute knee injury
2. Have an age-appropriate differential diagnosis for the limping child
3. Review the evidence for the diagnosis of septic arthritis in a child
4. Develop an approach to closed ankle injuries in children
5. Be able to assess children with a FOOSH
6. Be able to diagnose a supracondylar fracture and properly assess it
82
CASE 1:
KNEE INJURY
A mother presents to the emergency department with her 12-year-old son. While
playing basketball in gym class, he planted his foot and rotated his left leg following
a jump, resulting in a fall to the ground. He had to be carried off the court. He
complains of severe pain in his left knee and says he cannot put weight on it. He
says he may have heard a “pop” as he planted. He denies any other injury and is
previously healthy with no medications or significant medical history.
On exam, his vitals are within normal limits. His left knee is swollen, with a
ballotable effusion and is very tender to the touch diffusely. He is unable to extend
completely and can flex only to about 45 degrees. There appears to be anterior
laxity of the knee. He is unable to bear weight.
Q: This history and physical exam are classic indicators of what

diagnosis?
A: The mechanism for an anterior cruciate ligament (ACL) rupture is classically rotation
of the knee against an immobile foot, with sudden deceleration, often in sports such
as basketball, tennis, and soccer. Often a “pop” is felt or heard, and significant swelling
usually occurs within the first hour after injury with minimal ability to bear weight.
Q: What is the most sensitive physical exam manoeuvre for ACL rupture?
A: A meta-analysis from 2003 showed that the pivot shift test was the most sensitive
(88.8%), followed by the Lachman test (77.7%), with the anterior drawer test having a
sensitivity of only 22.2%. All three of these tests have a specificity of more than 95%.
Video: Click here

for a video on
Clinical Pearl:
how to perform
Always do a straight leg raise to rule out injury of the physical exam
extensor mechanism of the knee for any knee injury. manoeuvres for
ACL tears.
83
Q: For a patient with a suspected ACL tear, is an X-ray required? Does

the clinical decision rule, the Ottawa Knee Rules, apply to children?
A:
The Ottawa Knee Rules
A knee x-ray is indicated if ANY of the following is present:

•• Age > 55 (clearly can be omitted in pediatrics )
•• Pain at the fibular head
•• Isolated patellar tenderness
•• Inability to flex the knee to 90 degrees
•• Inability to walk four weight-bearing steps both immediately and in
the ED
The Ottawa Knee Rules are 100% sensitive in children for clinically significant
fractures and help reduce X-rays by 31%. Note that the patient in our case would
require an X-ray per the Ottawa Knee Rules regardless of a suspicion of an ACL
tear, because of the inability to bear weight.
A: Associated with ACL injuries, particularly in younger patients, are:

1. Tibial spine fracture
2. Segond fracture, a vertically oriented avulsion fracture off the lateral
proximal tibia
Tibial spine fracture Segond avulsion fracture
84
Caution! Q: What additional X-ray views should

I consider obtaining aside from the A-P
In general, children’s and lateral, for suspected tibial spine and
ligaments are stronger plateau fractures?
than their bones, and
so fractures are more A: Tibial spine and tibial plateau fractures are best
likely than sprains. seen on a “tunnel view.”
Therefore, have a low
threshold for ordering
X-rays in children.
Through adolescence
and adulthood the
opposite is true, as
bones become stronger
than ligaments, and so
sprains are more likely
than fractures.
85
Q: What is the ED management of suspected

ACL rupture?
A: Removable splint as needed, crutches, and ROM

exercises as tolerated until the patient can be re-
Some experts
examined in two to three days or up to five days
recommend no
later, once the swelling and pain have improved.
immobilizers for these
so-called “soft tissue
In general, patients with ligamentous injuries of the
injuries,” with weight
knee (not only ACL injuries but also MCL injuries, or
bearing as tolerated.
patients whose injuries you are unsure of but whose
X-rays are negative and you suspect a ligament or
meniscus injury) should be encouraged to remove
their immobilizers and begin gentle range-of-
motion exercises in two to three days to avoid
quadriceps atrophy, which would lead to prolonged
rehabilitation.
ACL tears are being repaired more frequently in

pediatrics than in the past. However, there’s no
rush to get them to the surgeon, as most surgeons
Clinical Pearl:
recommend delaying surgery until full range of Children who present
motion has been recovered. with knee pain often
have a diagnosis arising
Any displaced fractures or fractures with an impaired from the hip as a source
extensor mechanism associated with a suspected of their pain, so look
ACL rupture need urgent orthopedic consultation. proximally if the clinical
picture doesn’t fit.
86
CASE 2:
THE CHILD WITH A LIMP
A two-and-half-year-old girl who attends daycare presents to the ED with
a two-day history of limp and refusal to weight bear. Her parents report
a temperature of 38.2oC at home for the past two days and say that she’s
not eating and drinking as much as usual. They brought her in because
today, when they attempted to move the child’s leg, she started to cry.
There has been no significant recent trauma, except for a minor trip and
fall while running on the sidewalk three days prior. She has had a runny
nose and cough for the past three days, but no difficulty breathing, and
no vomiting, diarrhea, or rash. There has been no recent travel and no
contacts. She has no significant past medical history.
On exam, the child appears alert but anxious and in pain on Mom’s lap,
with no apparent respiratory distress. Vital signs reveal a temperature
of 37.9oC, a heart rate of 124, a respiratory rate of 30, and an oxygen
saturation of 99% on room air.
Her ENT exam is normal except for nasal discharge. Chest is clear.
There are a few scattered bruises on the shins. When you attempt any
movement of the right knee, the child cries. Palpation of the right hip
also elicits crying. The child refuses to bear weight when you attempt to
examine her gait.
Approach to a child with a limp
1. Rule out septic arthritis

2. Look for fractures—ask about traumas (can be subtle)
3. Look for signs of systemic illness, such as a rash, fever, bruising
4. Consider age-specific diagnoses as appropriate
87
Clinical Pearl:
If the initial physical exam is not revealing due to an unco-operative

child, give analgesia and re-examine the patient in 30 to 60 minutes.
Q. Does this child have a septic arthritis?
A: Septic arthritis should cross your mind for any monoarthropathy,

particularly in the hip, which is the most common site in children. There is no
single tool or piece of information that can reliably rule out or rule in septic
arthritis without obtaining a synovial fluid sample. However, there are tools
available to assist in making the decision whether to perform a joint tap.
Case continued: WBC count comes back at 14.5, CRP at 20, and ESR at 40.
Q. Can we use the information we have so far in this case to rule in

or out septic arthritis?
A: The Kocher Criteria can be a helpful tool to help risk stratify a patient
whom you suspect might have septic arthritis. It is best used as a rule in and
is not a very sensitive test on prospective validation. When all four criteria are
present, the probability of septic arthritis is 99.6%.
The Kocher Criteria
1. Non-weight-bearing on the affected side

2. ESR > 40 mm/hr
3. Fever
4. WBC count > 12,000
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Q. How useful is CRP in risk stratifying patients with suspected

septic arthritis?
A: On a retrospective review of 311 children with a hip effusion, those with a

CRP > 20 mg/l had an odds ratio of 81.9 of having a septic arthritis. However,
like other factors, it is neither specific nor sensitive enough to rule a septic
arthritis in or out. In the context of a low pre-test probability, negative CRP and
ESR have a fairly good negative predictive value.
Treatment: In patients in whom you suspect septic arthritis, usually you

can wait to start empiric IV antibiotics until after the joint can be aspirated.
However, if there will be a significant delay to joint aspiration, start antibiotics
on speculation.
Q. What is transient synovitis of the hip?
A: Transient synovitis of the hip is a self-limited inflammation of the synovial

lining. It is often preceded by a viral infection, and should resolve in three to
10 days. However, concurrent illness can make diagnosis challenging. Pay
attention to vital signs, general appearance and symptom progression. The
presence of an effusion on ultrasonography does not differentiate between
septic arthritis and transient synovitis.
FOAMed link: For more information on differentiating synovitis from septic

arthritis, see this post on Academic Life in EM blog here.
Q. What is the role of ultrasound in the workup of suspected septic

arthritis?
A: Most effusions can be detected by ultrasonography; however, effusions do

not differentiate septic arthritis from transient synovitis.
The sensitivity of ultrasound for an effusion is 95-100%. However, up to 5% of

septic hip ultrasounds can be negative initially, which typically occurs in early
presentations, less than 24 hours into the disease course.
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Investigating Septic Arthritis
Some experts suggest the following ultrasound-based algorithm:
Low pre-test Moderate pre-test Moderate pre-test

probability probability + < 24 probability + > 24
+ negative hours symptoms hours symptoms
ultrasound:
Ultrasound Ultrasound
Careful •• If negative, then •• If negative, then
outpatient repeat ultrasound discharge with
follow-up in 12 hrs or MRI follow-up
•• If positive then •• If positive, then
arthrocentesis arthrocentesis
for synovial fluid for synovial fluid
analysis analysis
Q: Next in the approach to the child with a limp after

differentiating transient synovitis from septic arthritis is
looking for fractures. What is the most commonly missed
fracture that presents in a toddler with a limp?
A: A commonly missed occult fracture is the toddler’s fracture (spiral

fracture in children nine to 36 months, usually of distal tibia). The
mechanism of injury is often minor (simple twisting mechanism) or there
is no report of injury at all! It can present with subtle physical exam and
X-ray findings. There is usually minimal or no swelling and subtle, difficult
to localize point tenderness. Pain with ankle dorsiflexion or calf rotation
should raise suspicion. Oblique views can help visualize the fracture and
increase X-ray sensitivity.
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Toddler’s fractures are treated with an above-knee immobilizing splint

with the knee in slight flexion, and orthopedic follow-up. However, if
X-rays are normal and symptoms are mild, consider follow-up without a
cast after discussing pros/cons with parents. If you have a high suspicion
despite a normal X-ray, consider a long leg splint with close follow-up.
Ultrasound can sometimes pick up the fracture if clinical suspicion is high
but X-rays are normal.
Toddler’s fracture
Q. Next in the approach to the child with a limp is ruling out

systemic illness. This can usually be assessed with a careful
history and a physical for signs and symptoms of systemic
illness such as rash, lethargy, etc. Finally, age-specific diagnoses
should be considered. Which age-specific diagnoses should we
consider in the child presenting with a limp?
A: Legg-Calvé-Perthes disease (LCPD) is an avascular necrosis of the

femoral head, typically seen in children ages four to 10. It can present
insidiously or may follow an injury. The initial X-ray can be normal or show
a very subtle change in femoral head appearance. Speak to the radiologist
on call to carefully review the images, and follow with a bone scan or MRI if
very suspicious.
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Slipped capital femoral epiphyses (SCFE) is easy to miss! It can present

subtly, with pain that radiates into the thigh or knee. Typical patients
are older children and those who are overweight, but also skeletally
immature. On exam, pain is usually greatest with internal rotation of the
hip, and they can present with the hip held in external rotation.
•• Get X-rays of both hips, including frog’s-leg view in addition to

standard views. Draw a Kline’s line from the external part of the
femoral neck, which should intersect part of the femoral head. As it
slips, the femoral head becomes medial to that line. Compare both
sides, but remember SCFE can be bilateral.
•• If suspicious, call orthopedics—these cases need surgical

management and SCFE will worsen if patients continue to bear weight.
Kline’s line for SCFE
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Q: Before leaving the subject of

the acutely limping child, what
discharge instructions should be
given to the parents for the limping
Non-accidental Trauma
child with an unclear diagnosis?
Some fractures should always
raise suspicion for non-accidental A: Avascular necrosis of the hip can be
trauma (i.e., posterior rib fractures). missed early in its course, so repeat
However, non-accidental trauma imaging may be required if there is no
can result in any type of fracture improvement of symptoms.
pattern. Always remember to be
systematic when taking histories, Septic arthritis can be missed early in its
and document carefully! Clues course, so arthrocentesis may be required
include: if fever progresses, systemic symptoms
and signs develop, or pain increases.
•• 1. Delay in presentation Toddler’s fracture can be easily missed on

•• 2. Vague or inconsistent X-ray, so a repeat X-ray may be required if
explanation of mechanism symptoms persist.
•• 3. Mechanism described that is
inconsistent with injury
•• 4. Injury inconsistent with
developmental stage of child
FOAMed link: Click here for a short

lecture on child abuse injury patterns
from Academic Life in EM.
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CASE 3:
ANKLE FRACTURES
A six-year-old boy is running during recess at school and twists his ankle. He’s
unable to walk afterward. On exam he’s tender and swollen maximally over the
distal fibula. The X-ray is normal.
Q: Do the Ottawa Ankle Rules apply in children?
A: Yes, a 2009 meta-analysis showed 98.5% sensitivity for ankle and

mid-foot fractures in children older than five years, with nearly all
the missed fractures being Salter-Harris I or classified as insignificant
fractures.
A 2001 prospective study showed 100% sensitivity in ruling out clinically significant
fractures in children using a “low-risk examination” technique where pain and
swelling are limited only to the distal fibula and its associated ligaments.
The Ottawa Ankle Rules
If any one of the following is present, the patient requires a

radiograph:
5. Tenderness of the posterior edge of distal 6 cm of the fibula
6. Tenderness of the posterior edge of distal 6 cm of the tibia
7. Tenderness of the head of the fifth metatarsal
8. Tenderness of the navicular
9. Unable to bear weight immediately and at the emergency
department
EM Cases Cross-link: For images and explanations on clinical decision rules, click
here for EM Cases’ Stiell Sessions 1: CDRs and risk scales.
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Q: What is the Salter-Harris pediatric fracture classification?
A: The Salter-Harris (SH) system classifies fractures involving the growth

plate of a long bone. These are common in the distal fibula. Fractures are
classified from I to V and can be remembered by the mnemonic SALTR:
•• I – S = Slip. Fracture of the cartilage of the physis (growth plate)

•• II – A = Above. Fracture above physis
•• III – L = Lower. Fracture below the physis in the epiphysis
•• IV – T = Through. Fracture is through the metaphysis, physis, and
epiphysis
•• V – R = Rammed. The physis has been crushed/heavily damaged
SH I and II fractures are the most common and rarely result in growth
arrest.
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MRI evidence suggests SH-I fractures are similar to a sprain, and

do well when treated as such. Non-displaced SH-II lateral malleolar Click here for
fractures (isolated non-displaced lateral malleolus fractures) heal the Canadian
as well in a removable over-the-shoe ankle air-stirrup brace with Paediatric Society
weight bearing as tolerated as in a cast or boot, but patients prefer statement on
an ankle air-stirrup brace, and mobilize earlier. pediatric ankle
sprains.
Two specific SH fractures are easy to miss in the

pediatric population:
1. Tillaux fracture is an intra-articular SH-III with avulsion of

the anterolateral tibial epiphysis, often from a low-energy
mechanism of external rotation of the foot or medial rotation
of the leg on a fixed foot in children with partial growth plate
fusion (ages 11–15). Pain and tenderness are at the anterior join
line of the ankle.
2. Look carefully for a distal tibia triplanar fracture in
adolescents (an unstable combination of SH-I, II and III), which
requires operative management.
Tillaux ankle fracture of the distal tibia Triplanar ankle fracture of the distal tibia
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CASE 4:
THE FAST FOOSH
A 12-year-old boy was running on the sidewalk. He tripped and fell on
his outstretched right hand. He complains of pain at his wrist only.
Examination from the elbow to the snuffbox reveals slight tenderness at
the distal radius. He is neurovascularly intact.
On X-ray there is a buckle fracture of the distal radius.
Q: What is a buckle fracture and how is it managed, compared

with a greenstick fracture and a transverse fracture of the distal
radius?
A: A buckle fracture, also known as a torus fracture, is an incomplete

fracture of a long bone that is commonly identified by bulging of the cortex.
The main mechanism is axial compression of soft, immature bones in
children.
Buckle fractures of the distal radius heal well in a removable splint, and
studies show that patients prefer this over a cast. A randomized, controlled
trial showed better physical function, less difficulty with activities, the ability
to return to sports sooner, and pain scores that are either not significantly
different when compared with a short arm cast or are lower than with
casting. There is even a study with just a soft bandage showing similar
outcomes compared with a short arm cast.
Not only that, but studies have shown that the removal of the splint can
safely be done at home rather than at a fracture clinic, guided by the child’s
symptoms. This of course assumes that the parents are agreeable, and are
given good discharge instructions with regard to when they might need to
seek medical care. In addition, parents prefer the removal of the splint at
home over having to follow up at a fracture clinic.
97
Minimally angulated greenstick fractures (one cortex broken, the other

intact) also do well with minimal splinting. Even minimally angulated
transverse distal radius fractures of less than 15 degrees can also be
treated effectively with a removable splint.
Minimally angulated buckle fracture of the distal radius
Q: What are the acceptable degrees of angulation in pediatric

distal radius fractures?
A:
•• < Five years old: up to 30 degrees is acceptable
•• Five to 10 years old: up to 20 degrees is acceptable
•• Ten to 12 years old: up to 15 degrees is acceptable
Caution!
Bone in children remodels well in the dorsal/volar plane but not in the
radial/ulnar plane, so if there is any displacement in the radial/ulnar
plane, it usually needs to be reduced. On the other hand, if there is
displacement in the dorsal/volar plane, you can accept more angulation
and the bone will remodel well.
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CASE 5:
THE FULL FOOSH
A 12-year-old boy was running on the sidewalk.
He tripped and fell on his outstretched right
hand. He complains of pain at his wrist only.
Examination from the elbow to the snuffbox
Clinical Pearl:
reveals slight tenderness at the distal radius. He is
neurovascularly intact. Five per cent of children
with elbow fractures will
Q: What are the most common fractures in have a second fracture
general we can expect to see with a FOOSH at a distal site (at the
mechanism? wrist, for example),
so it is imperative to
A: From distal to proximal: scaphoid, distal radius, examine the joint above
radial head, suprachondylar, proximal humerus, and and below the elbow for
clavicle fractures. all children with elbow
injuries.
Q: Suprachondylar fractures are the most
common elbow fractures in children and are
rarely seen in patients older than 15 years.
How should we assess neurologic status
in children suspected of a suprachondylar
fracture?
A: Suprachondylar fractures have a high risk of

neurologic and vascular injuries.
Brachial artery injury is reported in up to 20% of

displaced fractures, with 80% of these regaining pulses
after closed reduction.
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Clinical Pearl:
If the distal pulses are not palpable after a suprachondylar fracture,

the child will usually be holding their arm in extension. Try flexing at
the elbow 15 to 20 degrees and splint while waiting for emergency
reduction.
The anterior interosseous nerve injury is the most common nerve injury
in extension-type injuries, while ulnar neuropathy is the most common in
flexion-type injuries.
To test motor function of the anterior interosseous nerve, look for

weakness in flexors of IP joint of thumb and DIP joints of index and middle
fingers by observing how the patient pinches using their thumb and index
finger. Normally when an individual pinches something between their
index finger and thumb, the MP and IP joints of the thumb and index finger
are flexed; with nerve damage, the distal phalanges of the thumb and index
finger are extended or hyper-extended.
Abnormal Normal
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Upper Extremity Peripheral Nerve Testing
Ask the child to do hand signals to test motor function of each nerve.
•• Radial nerve: make a “thumbs up”
•• Median nerve: make a fist, and pinch a piece of paper with a pincer grip
•• Ulna nerve: make scissors with the index and middle finger, or a “peace” sign
For the sensory examination, test the first dorsal webspace (radial), and the
dorsum of the second or third fingertip (median) and fifth fingertip (ulna).
Pitfall:
Avoid multiple attempts at closed reduction, given the vulnerable position of

the neurovascular structures.
Q: Compartment syndrome is a potential complication of

suprachondylar fractures. How can the chances of compartment
syndrome be minimized, and what would make you suspect
compartment syndrome in a child with a suprachondylar fracture?
Pitfall:
Flexing the elbow to 90 degrees when immobilizing a patient with a

suprachondylar fracture who has significant swelling may increase the risk
of compartment syndrome, as this will decrease blood flow.
101
Q: What is your approach to the pediatric elbow X-ray?
1. “Figure of eight sign”: Confirms a true lateral (see image)

2. Anterior fat pad (“sail sign”): An enlarged, sail-shaped
hypodensity should raise suspicion of a fracture
3. Posterior fat pad: Any hypodensity posterior to the humerus
Clinical Pearl:
should raise suspicion of a fracture
4. Radio-capitellar line: A line through the middle of the radius Consider X-ray
normally bisects the capitellum; any disruption of this line of opposite
should raise suspicion of a fracture elbow for
5. Anterior humeral line: A line along the anterior border of comparison.
the humerus should bisect the middle third of the capitellum;
any disruption should raise suspicion for a fracture
6. CRITOE: Capitellum, Radial head, Internal epicondyle,
Trochlea, Olecranon, External epicondyle; review each
ossification centre, which appears approximately every two
years from ages two to 13 to rule out an avulsion fracture
masquerading as an ossification centre
1. “Figure of eight sign” confirms a 2. Anterior “sail sign”

true lateral
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3. Posterior fat pad 4. Radio-capitellar line
5. Suprachondylar fracture with posterior fat pad

(left) and anterior humeral line (right)
6. CRITOE mnemonic for

elbow growth plates
Capitellum
Radial head
Internal (medial) epicondyle
Trochlea
Olecranon
External (lateral) epicondyle
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Q: How should suprachondylar fractures

be managed in the ED?
Pitfall:
A: Suprachondylar fractures should be Do NOT apply a circumferential

immobilized in an above-elbow splint with the cast for suprachondylar
elbow at > 90 degrees of flexion and lots of fractures as it increases the risk
padding. Orthopedic consultation in the ED for neurovascular damage and
is necessary for all displaced suprachondylar compartment syndrome.
fractures. Non-displaced fractures can be
immobilized and followed up by an orthopedic Flexing the elbow to 90
specialist. degrees when immobilizing a
patient with a suprachondylar
FOAMed Link: Click here for a video tutorial on fracture who has significant
suprachondylar fractures on Radiopaedia. swelling may increase the risk
of compartment syndrome, as
this will decrease blood flow.
Comments?
Click here to leave a comment or
to listen to this podcast.
104
KEY REFERENCES:
1. Scholten RJ, Opstelten W, van der Plas CG, Bijl D, Deville WL, Bouter LM. Accuracy of physical
diagnostic tests for assessing ruptures of the anterior cruciate ligament: a meta-analysis. J Fam
Pract. 2003; Sep;52:689-694.
2. Stiell IG, Wells GA, Hoag RH, et al. Implementation of the Ottawa Knee Rule for the use of
radiography in acute knee injuries. JAMA. 1997; Dec;278(23):2075-9.
3. Bulloch B, Neto G, Plint A, et al. Validation of the Ottawa Knee Rule in children: a multicenter
study. Ann Emerg Med. 2003; Jul;42(1):48-55.
4. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient
synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg
Am. 1999; Dec;81(12):1662-70.
5. Kocher MS, Mandiga R, Zurakowski D, Barnewolt C, Kasser JR. Validation of a clinical prediction
rule for the differentiation between septic arthritis and transient synovitis of the hip in children. J
Bone Joint Surg Am. 2004; Aug;86-A(8):1629-35.
6. Singhal R, Perry DC, Khan FN, et al. The use of CRP within a clinical prediction algorithm for the
differentiation of septic arthritis and transient synovitis in children. J Bone Joint Surg Br. 2011;
Nov;93(11):1556-61.
7. Stiell IG, Greenberg GH, Mcknight RD, Nair RC, Mcdowell I, Worthington JR. A study to develop
clinical decision rules for the use of radiography in acute ankle injuries. Ann Emerg Med. 1992;
Apr;21(4):384-90.
8. Dowling S, Spooner CH, Liang Y, et al. Accuracy of Ottawa Ankle Rules to exclude fractures of the
ankle and midfoot in children: a meta-analysis. Acad Emerg Med. 2009; Apr;16(4):277-87.
9. Boutis K, Komar L, Jaramillo D, et al. Sensitivity of a clinical examination to predict need for
radiography in children with ankle injuries: a prospective study. Lancet. 2001; Dec;358(9299):2118-
21.
10. Boutis K, Willan A, Babyn P, Goeree R, Howard A. Cast versus splint in children with
minimally angulated fractures of the distal radius: a randomized controlled trial. CMAJ. 2010;
Oct;182(14):1507-12.
11. Plint AC, Perry JJ, Correll R, Gaboury I, Lawton L. A randomized, controlled trial of removable
splinting versus casting for wrist buckle fractures in children. Pediatrics. 2006; Mar;117:691-697.
12. West S, Andrews J, Bebbington A, Ennis O, Alderman P. Buckle fractures of the distal radius are
safely treated in a soft bandage: a randomized prospective trial of bandage versus plaster cast. J
Pediatr Orthop. 2005; 25(3):322-5.
13. Al-Ansari K, Howard A, Seeto B, Yoo S, Zaki S, Boutis K. Minimally angulated pediatric wrist
fractures: is immobilization without manipulation enough? CJEM. 2007; Jan;9(1):9-15.
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CHAPTER 7:
POCUS NERVE BLOCKS
LISTEN TO THE PODCAST WITH JASON FISCHER HERE
Objectives
1. Understand the indications for performing forearm nerve blocks
2. Identify the radial, ulnar, and median nerve with POCUS
3. Perform the steps of POCUS-guided forearm nerve blocks of the radial,
ulnar, and median nerve
4. Understand the complications and pitfalls of performing nerve blocks
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Q: Why should you care?
A: Pain relief is one of the most important roles an emergency physician can perform,
especially on a child. If a child has a painful experience in the emergency department,
it is likely they will fear future pain, doctors, and hospitals. A properly performed
forearm nerve block may not only completely eliminate a child’s pain, but may also
prevent future negative attitudes toward hospitals and health-care providers.
CASE 1:
THE CASE OF PUTTING OUT FIRES WITH POCUS
Q: A four-year-old boy is brought into the
emergency department after a firecracker
exploded in his closed hand. Among other
investigations and treatment, the child
needs quick and effective pain relief. What
are some of your options?
A: While analgesics such as IN fentanyl and IV

morphine have a rapid onset of action of a few
minutes, they rarely eliminate the pain completely
and often wear off before a definitive repair of
injuries is performed in the operating room. A
properly performed forearm nerve block will
rapidly and completely eliminate all of the pain
for hours until the patient can be taken to the
operating room for surgical repair.
Q: This case is a great example of a good indication for a forearm nerve

block. What other situations would a forearm block be ideal for, where
pain control might otherwise be challenging?
A: •• Boxer’s fractures •• Crush injury

•• Multiple lacerations or complex lacerations •• Abscess incision and drainage
•• Burns requiring debridement and bandaging
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Caution:
Forearm nerve blocks provide analgesia only to the hand, not the forearm.
They are indicated only for significant hand injuries, not for forearm injuries.
Q: You agree that an ultrasound-guided forearm nerve block is

the best option for pain relief in this case. How do you prepare
for a forearm nerve block?
A: Step 1: Position
The patient should be placed in a position of comfort that allows the target
limb to be accessible to the ultrasound probe. This is usually achieved by
having the patient sit in a chair with their arm prone on a bedside table.
The ultrasound screen and the injection site should be aligned in the
operator’s direct line of vision to reduce unnecessary head movement.
108
Clinical Pearl:
Use of tape, trays, or papoose to reduce the child’s movements (especially

infants and toddlers) may be necessary to keep the targeted limb
immobilized for the procedure.
Step 2: Preparation
To minimize the anxiety and pain experienced by this four-year-old boy,

apply a topical anesthetic to the area where the needle is to be inserted.
Also, providing an intranasal analgesic such as ketamine or fentanyl may
help the child tolerate the procedure.
For more on topical anesthetics and intranasal medications in pediatric

pain management, go to Chapter 3 on Pain Management or Chapter 5
on Procedural Sedation.
Q: Now that you’ve prepared for the procedure, it’s time to

identify the nerves you’d like to block. How do you identify
the radial, ulnar, and median nerves?
A: Step 3: Nerve identification
Peripheral nerves have a “honeycomb” appearance, round or elliptical,

with hypoechoic fascicles in a hyperechoic homogenous background.
Using the high-frequency linear probe placed in the transverse plane at
the level of the wrist, identify either the radial or ulnar artery. Then move
proximally up the arm to locate the nerve.
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The radial nerve will lie “radial” to the radial artery.
The ulnar nerve will lie “ulnar” to the ulnar artery.
110
The median nerve

does not have an
associated artery,
but is located in
the mid-forearm
(between the radial
and ulnar nerve) in
the flexor digitorum
muscle bundles.
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FOAMed Resource and Videos
For more FOAMed resources and video instruction on how to identify

the forearm nerves with POCUS, please visit:
•• How to identify the radial nerve – video by Dr. Mike Stone

•• How to identify the ulnar nerve – video by Dr. Mike Stone
•• How to identify the median nerve – video by Dr. Mike Stone
Step 4: Anesthesia delivery
Q: It’s time to inject the anesthetic. Which “plane” is used when

performing a forearm nerve block to best identify the needle tip?
A: Advance the needle tip “in-plane” toward the target nerve. This provides
superior visualization of both the nerve and the needle over the “out-of-
plane” view (see image).
112
Clinical Pearl:
Buffer your
lidocaine with
bicarbonate to
make injecting
the lidocaine less
painful.
Radial nerve
Ulnar nerve
113
Q: How is the anesthetic delivered to ensure that the nerve will be

bathed in anesthetic without injuring the nerve, and what should
the ultrasound screen look like after delivery of the anesthetic?
A: When the needle tip is adjacent to the nerve (but not in the nerve), inject
the anesthetic so it surrounds the nerve circumferentially. If the nerve is
bathed circumferentially with anesthetic (an anechoic area completely
surrounding the nerve), clinically the patient should feel fully anesthetised in
that nerve distribution. Multiple redirections of the needle may be necessary
to bathe the nerve adequately. Visualization of the needle tip should be
continuous throughout the procedure to avoid accidental puncture of
vascular structures.
Lidocaine (blue arrow

pointing at black area) from
the needle (yellow arrows)
accumulating around the
nerve (blue circle)
Caution:
Ensure you have performed a full neurological exam of the child’s distal
extremity before you perform a nerve block, and document it for your
colleagues who may take over care. Once the anesthetic has been
administered, the neurologic exam will be compromised (loss of ability to
check two-point discrimination). Also ensure that compartment syndrome has
been ruled out before performing the nerve block.
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Caution:
Lidocaine is a safer drug for nerve Toxic dose of lidocaine:

blocks than bupivacaine, and adding
epinephrine to the lidocaine will •• 5 mg/kg with epinephrine
provide a prolonged analgesic effect •• 3 mg/kg without epinephrine
compared with lidocaine alone.
Q: In this case, the four-year-old boy is moving his arm a bit and you
lose visualization of the needle on the screen. What are the best ways to
troubleshoot this?
A: Complications arise from losing the needle tip (damaging other structures, hitting
vessels, going through a nerve). Try to visualize the needle tip on screen at all times
before advancing it and always withdraw the plunger on the syringe to confirm that
the needle is not inside a vessel before injecting the local anesthetic. If you lose your
needle tip, don’t panic. Move only one component at a time to re-identify your needle.
You can either hold the ultrasound probe still while re-direct your needle back into
view by moving it more “in-plane” with the probe, or you can hold your needle still and
slowly move your ultrasound probe to visualize your needle on the screen.
Case resolution: Immediately after you block the radial,

ulnar and median nerves of this four-year-old boy, he rates Comments?
his pain on the Faces Pain Scale–Revised as 0 out of 5. Click here to leave a
Three hours later, as he is rolled into the operating room, comment or to listen to
he is smiling and chatting with the surgeon without any this podcast.
signs of pain.
115
KEY REFERENCES:
1. Frenkel O, Mansour K, Fischer JW. Ultrasound-guided femoral nerve block for pain control
in an infant with a femur fracture due to non-accidental trauma. Pediatr Emerg Care. 2012;
Feb;28(2):183-4.
2. Liebmann O, Price D, Mills C, et al. Feasibility of forearm ultrasonography-guided nerve blocks
on the radial, ulnar, and median nerves for hand procedures in the emergency department. Ann
Emerg Med. 2006; Nov;4(5):558-562.
3. Herring AA, Stone MB, Fischer J, et al. Ultrasound-guided distal popliteal sciatic nerve block for ED
anesthesia. Am J Emerg Med. 2011; Jul;29(6): 697.
4. Ganesh A, Gurnaney HG. Ultrasound guidance for pediatric peripheral nerve blockade. Anesthesiol
Clin. 2009; Jun;27(2):197-212.
5. Ivani G, Mosseti V. Pediatric regional anesthesia. Minerva Anesthesiol. 2009; Oct;75(10):577-583.
6. Tsui BC, Suresh S. Ultrasound imaging for regional anesthesia in infants, children, and
adolescents: a review of current literature and its application in the practice of extremity and
trunk blocks. Anesthesiology. 2010; Feb;112(2):473-492.
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CHAPTER 8:
ABDOMINAL PAIN &
APPENDICITIS
LISTEN TO THE PODCAST WITH ANNA JARVIS & STEPHEN FREEDMAN HERE
Objectives
1. Develop an approach to assessing acute abdominal pain in the pediatric patient
2. Recognize the common pitfalls in accurately diagnosing appendicitis among
pediatric patients
3. Understand the role of laboratory investigations in assessing a pediatric patient with
acute abdominal pain
4. Develop an approach to the selection of imaging investigations for the pediatric
patient suspected of appendicitis
5. Understand how to interpret equivocal ultrasound results
6. Describe effective ways to provide analgesia for pediatric patients
7. Review the management of appendicitis in the ED
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CASE 1:
APPROACH TO PEDIATRIC ABDOMINAL PAIN
A seven-year-old boy presents to your ED at 9 p.m. with a history of diarrhea
and fever for two days, as well as vague abdominal pain. On further
questioning, he has no travel history, his immunizations are up to date, there
are no known viral contacts, and he is otherwise healthy on no medications.
He vomited once that morning, has no urinary symptoms, no URI symptoms,
and no rash. On exam, his vital signs are normal except for a temperature of
38.1°C. His abdomen is soft, with slight diffuse tenderness, and no peritoneal
signs. The rest of his exam is normal.
Q: You begin by considering your

differential diagnosis. What are
the most common diagnoses for
pediatric abdominal pain in the ED?
A: In order of prevalence, the most

common diagnoses for pediatric
abdominal pain are:
1. Gastroenteritis
2. Respiratory tract infection (including
otitis media, pharyngitis, and
pneumonia)
3. UTI
4. Constipation
5. Appendicitis
Caution:
Only 1-2% of kids who present with abdominal pain will have a surgical diagnosis,
yet these conditions can lead to significant morbidity and mortality if they are not
diagnosed and managed appropriately in the ED. Children with a so-called “classic”
gastroenteritis presentation may actually end up having a perforated appendicitis,
while those with significantly tender bellies may have pneumonia, strep throat, or DKA.
118
Case continued: A urine dip is normal. A stool for culture and sensitivity is
sent off, the boy is rehydrated with an oral rehydration solution in the ED, and
a diagnosis of gastroenteritis is made. The patient is sent home with the usual
gastroenteritis instructions.
Q: How accurate are ED physicians at making the diagnosis of

appendicitis?
A: Despite being the most common surgical diagnosis for pediatric abdominal
pain, appendicitis remains a very difficult diagnosis to make in the ED, with a
misdiagnosis rate between 28% and 57% on the initial visit.
Q: How does the rate of perforation of the appendix change with age?
A: Delays in diagnosis are reflected in the high rate of perforation among

pediatric patients with appendicitis. About one-third of children will have a
perforated appendix discovered in the operating room. The rate of perforation
is even higher among children younger than three years old, reaching as high
as 80%–100%. These delays to diagnosis are associated with increased risk of
intra-abdominal abscess formation, small bowel obstruction, and prolonged
hospitalization.
Q: Why are we not terribly accurate in diagnosing appendicitis in

children clinically?
A: The challenges in diagnosis are attributed largely to the

frequent absence of the classic history of anorexia and vague
periumbilical pain followed by migration to the right lower
Clinical Pearl:
quadrant, low grade fever, and vomiting. An atypical presentation
is very typical for pediatric appendicitis, with fewer than 60% of The younger
patients presenting with a “classic history.” the patient, the
more wary a
Anatomic position of the appendix can alter the presenting clinician should
symptoms. Patients with a retrocecal appendix can present with be of an atypical
pain localized to the psoas muscle or back rather than RLQ. presentation.
119
The more atypical the presentation, the more likely the

diagnosis will be missed on the initial visit. Add to this
that the presence of features suggestive of alternative
diagnoses—such as mild poorly localized pain, diarrhea, Clinical Pearl:
constipation, dysuria, upper respiratory symptoms, Contrary to adult
absence of fever, and a good appetite—and it is easy to appendicitis, vomiting
understand how a physician could be led astray. may occur before the
onset of abdominal
Q: Since many children under the age of two pain in children.
years will present with a ruptured appendix,
what signs and symptoms should you look for
to assess for a ruptured or perforated appendix?
A: Patients with a perforated appendix will often report

an interval of pain relief prior to developing severe
Caution:
generalized pain, peritonitis, and a high temperature Parents also often
(> 39°C). Inflammatory markers such as a CRP or ESR present to the ED very
are also more likely to be elevated. early in the course of
the illness when the
Q: The next day, the boy returns with worsening signs and symptoms
abdominal pain, persistent vomiting, and an have not fully declared
elevated temperature of 39.8°C. You re-examine themselves.
the child. What should you pay close attention
to on physical exam?
A: It is important to recognize that extra-abdominal

etiologies can present as abdominal pain in children,
and to examine the patient accordingly. In addition
Clinical Pearl:
to examining the abdomen, the physician should also
examine the patient’s ears, pharynx, skin, back, lungs, With a delayed onset
and external genitalia. An internal gynecologic exam of diarrhea following
should be performed in the appropriate context, such two or more days of
as adolescent patients who are sexually active. abdominal pain, think
ruptured appendicitis!
120
Before palpating the abdomen, observe the child’s behaviour and preferred
position. Patients with appendicitis often prefer to lie still with their hips flexed.
Restless movements are more suggestive of intussusception. You can also ask the
child to cough, jump, or sit up in bed to elicit peritoneal tenderness, although these
have poor predictive value. Proceed next with percussion to localize tenderness
and detect peritonitis while minimizing discomfort, and then finally with palpation.
Caution: Clinical Pearl:
Always perform a testicular Consider ovarian torsion

exam on male pediatric patients in adolescent females with
with abdominal pain. Testicular sudden, near-simultaneous
torsion can present with onset of RLQ pain and
abdominal pain and vomiting. vomiting.
Physical Examination Strategies
Ways to calmly facilitate an abdominal exam on a crying or frightened child:

•• Place your hand on top of the child’s hand when palpating
•• Use a stethoscope to palpate to distract the child by saying you are listening to
their tummy
•• Start by palpating the parent’s or a stuffed animal’s abdomen to demonstrate the
benign nature of the exam
•• Have the parent hold the child facing them, with the child’s head resting on the
parent’s shoulder; then palpate the abdomen by wrapping your hands around the
child’s waist from behind
•• Ask the parent to palpate the abdomen
•• Have the parent bounce the child on their knee to elicit peritoneal signs
•• Have the parent lie with the child on the stretcher to help the child feel safe and
secure during the exam
•• Start at the ankles palpating up to the abdomen. You can also lift and roll the legs
to elicit psoas irritation
121
Q: Next, you begin to consider whether you need to poke this child
for blood work. What is the value of obtaining a complete blood
cell (CBC) count on pediatric patients with abdominal pain?
A: No laboratory marker can be used in isolation to definitively rule in or rule

out appendicitis.
A CBC count, and in particular a WBC count, is of limited utility in diagnosing

the cause of pediatric abdominal pain. The likelihood ratios (LR) associated
with the presence or absence of leukocytosis are not sufficient to either rule
in or rule out appendicitis. Children with gastroenteritis may have a high
white count with a left shift, while as many as 40% of those with appendicitis
may have no leukocytosis. Nonetheless, a normal WBC count does make the
diagnosis less likely.
Key Reference:
In a study of 755 kids, the absence of leukocytosis was of greater negative

predictive value than the absence of physical exam findings and symptoms. A
WBC count of <10,000 (LR 0.18) and absolute neutrophil count (ANC) of < 7,500
per cubic millimetre (LR 0.35) had lower likelihood ratios for appendicitis than
a lack of percussive tenderness (LR, 0.50), lack of guarding (LR 0.63), or absence
of nausea or emesis (LR 0.65).
The earlier the presentation, the less likely the WBC count will be elevated.
The WBC count is normal in first 24 hours in 80% of appendicitis cases.
122
Q: Is there a role for adding Q: You decide to order a CBC and

inflammatory markers to the blood a CRP given the child’s clinical
work to help diagnose appendicitis? course. Will you also include a
urinalysis in your standard workup
A: The role for both the erythrocyte for the child presenting with still
sedimentation rate (ESR) and CRP in undifferentiated abdominal pain?
diagnosing appendicitis among pediatric
patients remains unclear at present. A: A urinalysis is critical in screening for
Similar to a WBC count, both ESR and CRP alternative diagnoses when working up
lack the necessary sensitivity or specificity a child with abdominal pain. However,
to rule in or rule out a diagnosis of it is important to be mindful that a
appendicitis in isolation, especially among positive urinalysis can occur with
patients presenting within in the first 24 appendicitis.
hours of symptom onset. In addition, the
variable cut-off values for the CRP make Pyuria found on urinalysis is routinely
it difficult to compare its performance used as an indicator of an underlying
across studies and determine how it urinary tract infection. However, it
should be used. is often present in appendicitis due
to local irritation from an inflamed
Some literature suggests the sensitivity appendix on either the ureter or
of CRP does improve, and potentially bladder. As a result, the presence of
exceeds that of a WBC count 24 hours pyuria can be difficult to interpret when
after the onset of symptoms. Other both a UTI and appendicitis are included
studies have suggested CRP is best in a clinician’s differential diagnoses.
interpreted as a marker of disease The presence of 20 or more WBCs per
severity, with improved accuracy in high-power field (hpf) or bacteria on a
detecting gangrenous or perforated clean catch specimen favours a urinary
appendicitis. tract infection.
Interestingly, a single study demonstrated

a near 90% specificity for appendicitis
when both the WBC count and CRP are
elevated.
123
Caution:
Pyuria and hematuria are findings that can be consistent with the
diagnosis of appendicitis. Don’t let the findings of pyuria or hematuria
dissuade you from diagnosing appendicitis in a child whom you suspect
has appendicitis clinically.
A human chorionic gonadotropin urine test to screen for pregnancy

among sexually active adolescent patients is an important consideration
in undifferentiated abdominal pain. DKA can present with abdominal
pain and vomiting. A urinalysis is also valuable to evaluate for ketosis and
hyperglycemia.
For more on pediatric DKA, jump to Chapter 11.
Q: You have heard about multiple clinical decision rules for

pediatric appendicitis. How should you incorporate these into
clinical practice?
A: There are three published decision rules for pediatric appendicitis: the
Refined Low-Risk Appendicitis Score, the Pediatric Appendicitis Score, and
the Alvarado Score.
Each of these scores has varying sensitivities (65%–98%) and specificities

(32%–92%) and are rarely used as definitive confirmation of the diagnosis,
but knowing what is listed in them is useful for teaching purposes and as
pieces of the puzzle to help weigh our decisions.
124
The Alvarado
Score for
Predicting Acute
Appendicitis
Click here for details

of a systematic review
of the Alvarado Score.
125
The Pediatric Appendicitis Score

Click here
for details of
the Pediatric
Appendicitis
Score and
the Refined
Low Risk
Appendicitis
Score.
Refined Low Risk Appendicitis Score
126
Clinician gestalt of an experienced ED physician may be as good as any of

these scores, but if you are early in your emergency medicine career, any of
these three clinical decision rules may help in your decision-making if the
score is very low or very high.
FOAMed Link: For more on appendicitis decision rules, visit emDocs here.
Case continued: The results are returning on your patient and you
summarize your findings. On examination, the patient seems to be in
moderate discomfort, and prefers to lie still on the stretcher. Palpation
of the abdomen reveals rebound tenderness in the RLQ. Laboratory
testing is remarkable for an elevated WBC count of 14 and a normal
urinalysis. You remain concerned that this child has appendicitis and
order an ultrasound.
Q: While awaiting imaging, what are some options for treating this
patient’s pain?
A: The myth has long been dispelled that providing analgesia can mask
physical exam findings leading to misdiagnosis in appendicitis.
Pediatric Pain Management
Typical pediatric dosages for parental opioid analgesia:

•• Morphine 0.05 to 0.1 mg/kg IV q2h up to 8 mg/dose
•• Hydromorphone 0.02 mg/kg IV q2h
•• Fentanyl 1 mcg/kg IV Q1-2h
For more on pediatric pain management, jump to Chapter 3: Pain

Management.
127
Q: Your ultrasound report comes back and you are reading

through the radiologist’s findings. What are the ultrasound
diagnostic criteria for appendicitis?
A: As a modality that does not expose patients to radiation, ultrasound

is the preferred initial imaging for pediatric appendicitis, with a reported
sensitivity and specificity between 88% (95% CI 86%–90%) and 94% (95%
CI 92%–95%), respectively.
The following features of a directly visualized appendix

support a diagnosis of appendicitis:
1. An aperistaltic, non-compressible, hyperemic, dilated
appendix (> 6 mm)
2. Appendiceal wall thickening > 1.7 mm
3. Presence of an appendicolith
Secondary signs suggestive of appendicitis when you are

unable to fully visualize the entire appendix include:
1. Periappendiceal free fluid
2. Enlarged mesenteric lymph nodes
3. Increased fat echogenicity
4. Fluid in the lumen of the appendix
For a the role of ED Point of Care Ultrasound in the

diagnosis of pediatric appendicitis, jump to Chapter 9.
Q: How should a clinician interpret an ultrasound report that

states the appendix could not be seen?
A: The interpretation of an ultrasound report where the appendix is

not seen will depend both on the pre-test probability from your clinical
impression, initial laboratory investigations, and the presence or absence
of secondary signs of appendicitis.
128
An ultrasound where the appendix is not seen can still provide valuable information. The
absence of any secondary signs of appendicitis makes a final diagnosis of appendicitis
very unlikely. One study found a 0.90 (95% CI 0.83-0.95) negative predictive value in
the absence of secondary signs of appendicitis among ultrasound results where the
appendix was not seen.
Q: What should be the next step if you remain concerned that a patient may
have appendicitis and the ultrasound was inconclusive?
A: This is an area of great practice variability from centre to centre and between
individual physicians.
In the context of high clinical suspicion, consultation with a pediatric surgeon or

proceeding with a low-dose CT would typically be pursued. With a sensitivity of 92%–
100%, and specificity of 89%–98%, CT has a high likelihood of being able to definitively
rule in or rule out a diagnosis in a timely fashion.
In the event that the initial ultrasound is inconclusive for a well-appearing child with a
low to moderate clinical pre-test probability, one approach is to have the child return
to the ED in 12 to 24 hours to be reassessed and potentially repeat the ultrasound.
This strategy avoids the radiation exposure of a CT, while capitalizing on the improved
diagnostic accuracy of ultrasound examination with the increased duration of symptoms.
A secondary analysis from a prospective trial on children with suspected appendicitis
demonstrated that the sensitivity of ultrasound improved from 86% within the first 12
hours after the onset of symptoms to 96% after 48 hours.
Clinical Pearl:
While the accuracy of ultrasound for the diagnosis of appendicitis increases

with time from onset of symptoms, the accuracy of CT does not change with
time. It is therefore reasonable to repeat an abdominal ultrasound in 12 to
24 hours for patients with a low or moderate probability of appendicitis with
an equivocal initial ultrasound, who present early after symptom onset.
129
FOAMed link: For more on ultrasound versus CT for appendicitis, visit the
Academic Life in EM blog.
Case continued: On repeat ultrasound, a diagnosis of uncomplicated

appendicitis it made.
When you call the pediatric surgeon you are informed that they
are in the operating room and should be down to see the patient
in the next two hours. While waiting for the surgeon to arrive
you decide to start antibiotics. What is the role for antibiotics in
acute appendicitis? And which antibiotics should be used?
A: In patients with non-perforated appendicitis, children should receive

preoperative broad-spectrum antibiotics to decrease the incidence of
wound infection and abscess formation; however, the antibiotics do not
need to be administered in the ED.
Broad-spectrum single- or double-agent therapy is as effective as, and

more cost-effective than, triple-agent therapy for the treatment of
perforated appendicitis.
Comments?
comment or to listen
to this podcast.
130
KEY REFERENCES:
1. Becker T, Kharbanda A, Bachur R. Atypical clinical features of pediatric appendicitis. Acad Emerg
Med. 2007; Feb;14(2):124-9.
2. Bundy DG, Byerley JS, Liles EA, Perrin EM, Katnelson J, Rice HE. Does this child have appendicitis?
JAMA. 2007; Jul;298(4):438-51.
3. Kharbanda AB, Casme Y, Liu K, Spitalnik SL, Dayan PS. Discriminative accuracy of novel and
traditional biomarkers in children with suspected appendicitis adjusted for duration of abdominal
pain. Acad Emerg Med. 2011; Jun;18(6):567-74.
4. Kwan KY, Nager AL. Diagnosing pediatric appendicitis: usefulness of laboratory markers. Am J
Emerg Med. 2010; Nov;28(9):1000-15.
5. Kharbanda AB, Dudley NC, Bujaj L, et al. Validation and refinement of a prediction rule to identify
children at low risk for acute appendicitis. Arch Pediatr Adolesc Med. 2012; Aug;166(8):738-44.
6. Kulik DM, Uleryk EM, Maguire JL. Does this child have appendicitis? A systematic review of clinical
prediction rules for children with acute abdominal pain. J Clin Epidemiol. 2013; Jan;66(1):95-104.
7. Goldman RD, Crum D, Bromberg R, Rogovik A, Langer JC. Analgesia administration for acute
abdominal pain in the pediatric emergency department. Pediatric Emerg Care. 2006; Jan;22(1):18-
21.
8. Estey A, Poonai N, Lim R. Appendix not seen: the predictive value of secondary inflammatory
sonographic signs. Pediatric Emerg Care. 2013; Apr;29(4):435-9.
9. Bachur RG, Dayan PS, Bajaj L, et al. The effect of abdominal pain duration on the accuracy of
diagnostic imaging for pediatric appendicitis. Ann Emerg Med. 2012; Nov;60(5):582-590.
10. Ohle R, O’Reilly F, O’Brien KK, et al. The Alvarado score for predicting acute appendicitis: a
systematic review. BMC Med. 2011; Dec;9:139.
11. Doria AS, Moineddin R, Kellenberger CJ, et al. US or CT for diagnosis of appendicitis in children
and adults? A meta-analysis. Radiology. 2006; Oct;241(1):81-94.
12. Lee SL, Islam S, Cassidy LD, et al. Antibiotics and appendicitis in the pediatric population: an
American Pediatric Surgical Association Outcomes and Clinical Trials Committee Systematic
Review. J Pediatr Surg. 2010; Nov;45(11):2181-2185.
131
CHAPTER 9: POCUS
APPENDICITIS &
INTUSSUSCEPTION
LISTEN TO THE PODCAST WITH ALEX ARROYO AND ADAM SIVITZ HERE
Objectives
1. Review the literature of POCUS in pediatric appendicitis
2. Learn the technique to perform appendicitis POCUS
3. Learn the technique to perform intussusception POCUS
4. Identify the target sign of intussusception
132
CASE 1: THE BIG SAVE

A 12-year-old boy complains of peri-umbilical pain for the past 24 hours. He presents
to a tertiary hospital with no pediatric capabilities. He has been refusing to eat food
and is now able to tolerate sips of fluid. A junior learner has done an assessment and
indicates the child is suffering from gastroenteritis, and wants to send the child home.
On bedside ultrasound, a non-compressible, tubular structure is seen in the right lower
quadrant with a diameter of 9 mm and peri-appendiceal fluid. The patient is transferred
to a pediatric centre at 1 a.m., and its 24-hour ultrasound department confirms acute
appendicitis. An uneventful appendectomy was performed at 6:30 a.m.
Appendicitis is notorious for its variability in clinical presentation, which can make it
challenging to diagnose. Blindly taking a patient to surgery without any imaging can lead
to a negative laparotomy, leading to complications. The current guidelines stipulate that
ultrasound should be the first line imaging modality for suspected pediatric appendicitis.
Ultrasound is a safe and useful tool to diagnose appendicitis, but unfortunately it is not
available 24 hours a day in many centres. Appendicitis Point of Care Ultrasound (POCUS)
may be an alternative in this case and save the patient radiation from a CT scan.
Q: Will the surgeons believe me when I tell them I’ve confirmed appendicitis
on POCUS? Can clinicians accurately diagnose appendicitis on POCUS?
A: Evaluation of acute appendicitis by pediatric emergency physician sonography
In a study of 264 pediatric patients with suspected

appendicitis, 13 pediatric emergency sonographers
performed appendicitis POCUS.
The sensitivities
Findings for appendicitis POCUS: and specificities
•• 85/264 had appendicitis for the diagnosis
•• Sensitivity of 85% and specificity of 93% for appendicitis of appendicitis
•• Positive LR of 11.7 and negative LR of 0.17 for appendicitis on POCUS by
emergency
Author’s conclusions: Pediatric emergency physicians can physicians are
diagnose acute appendicitis with substantial accuracy. comparable to
those found in the
radiology literature.
133
Q: The diagnosis and treatment of this 12-year-old boy with

appendicitis was expedited using POCUS. What does the
literature show about how appendicitis POCUS can improve ED
length of stay and limit CT rates?
A: In one study of 150 pediatric patients with suspected appendicitis,

appendicitis POCUS significantly decreased ED length of stay (154 minutes
versus 288 minutes). CT rates also decreased to 27% from 44%.
POCUS Radiology U/S CT Scan
Sensitivity 60% 63% 83%

Specificity 94% 99% 98%
Q: That sakes sense, but in this case,the patient still went on

to have a formal ultrasound. If emergency physicians can
accurately diagnose appendicitis at the bedside, which patients
require additional imaging after POCUS?
A: First, a pre-test probability is required to determine the need for further

testing. In a high-probability patient who has a negative appendicitis
POCUS, more definitive imaging is required. Conversely, in a very low-
probability patient who is otherwise well, a negative appendicitis POCUS
that is determinate does not require further imaging. In the medium-
probability patient (often the most diagnostically challenging), they may
require further testing based on the clinical features and POCUS findings.
In the medium-probability patient for appendicitis, the safest course

of action is to obtain additional tests if the appendicitis POCUS is not
obviously positive. These patients are the most diagnostically challenging
and may have other causes of their symptoms that need to be explored.
134
Q: Now that you have some data to support your

Pitfall: appendicitis POCUS practice, let’s move on to
the practicalities of doing the procedure. How do
Be careful not to you perform POCUS when you are suspicious of
misidentify the appendicitis?
terminal ileum or
another component A: First, choose the high-frequency probe (the linear
of the small bowel probe). Have the child point to the area of maximal
as the appendix by tenderness, and place the high-frequency probe at that
ensuring you are location. In a younger child who cannot express exactly
seeing a tubular, where the pain is located, a more systematic scanning
non-compressible technique is required. Identify the ascending colon in
structure. the lateral right side of the abdomen and slide down
the lateral wall to ensure findings of lateral or retro-
cecal appendicitis are not missed. Slide the probe to the
medial side of the cecum and ascending colon where the
appendix most likely comes off the cecum. To correctly
identify the appendix, ensure a tubular, non-compressible
structure is seen.
Once the appendix is located, trace the appendix all the

way to its blind end by sliding the probe.
POCUS findings to support the diagnosis of

appendicitis
1. Dilated appendix (> 6 mm)
2. Appendicolith
3. Distinct appendiceal wall layers
4. Echogenic prominent peri-cecal fat
5. Peri-appendiceal fluid collection
6. Target appearance
135
136
Step-by-Step Approach to Appendicitis POCUS
1. In an older child who is able to point to the location of their pain, place the
probe where they point. Younger patients require a more systematic scanning
technique.
2. Identify the ascending colon in the lateral right side of the abdomen. Move
down the lateral wall to make sure you are not missing a lateral or retro-cecal
appendix.
3. Move to medial side of the cecum and ascending colon; this is commonly
where the appendix comes off of the cecum.
4. To correctly identify the appendix, ensure you are seeing a tubular non-com-
pressible structure. (A common pitfall is to misidentify the terminal ileum or
another small bowel structure as the appendix.)
5. Once you locate the appendix, trace it all the way to its blind end.
FOAMed Link: For a challenging case of appendicitis POCUS on the EDE blog, go here
Video: Click here for a review of pediatric appendicitis POCUS.
137
CASE 2:
THE STOMACH ACHE
A 14-month-old female presents to your ED with the chief complaint
of crying intermittently for the past three hours. Her parents explain
that she vomited with each of these episodes. They report no blood
per rectum, no fevers, and that she was well prior to the episode. On
examination, the child looks very well but her parents tell you she seems
more tired that usual. You just had some training in POCUS and want to
keep up your skills, so you grab an ultrasound machine and place the
probe on the child’s abdomen. To your surprise, you immediately see
a target sign. Shortly afterward, the child once again develops severe
abdominal pain and vomits, but her pain resolves in a few minutes. You
call your local pediatric referral centre and refer your patient with the
diagnosis of intussusception.
Target sign of intussusception
138
Q: The patient doesn’t have the classic triad of abdominal pain, vomiting,
and bloody stool! Are you sure the diagnosis is intussusception?
A: Intussusception has a wide variety of presentations and age range. The classic
triad is seen in only 20% of cases. The lack of textbook presentation may lead
clinicians to initially miss the diagnosis, leading to complications such as bowel
obstruction and perforation. Using intussusception POCUS in children with
non-classic presentations who have abdominal pain or vomiting may capture
intussusception cases that may otherwise be discharged as gastroenteritis or viral
illnesses.
For more on intussusception, go to Chapter 10 on Gastroenteritis, Constipation and

Obstruction.
Q: In this case you got lucky by seeing the target sign immediately
after placing the ultrasound probe on the patient’s abdomen. But you
won’t be so lucky every time. What is your step-by-step approach to
intussusception POCUS?
A: Choose the high-frequency probe (also called the linear probe). Begin the scan
at a 6 cm to 8 cm depth, but you may need to adjust this based on the patient’s
body habitus. Start with the probe in the right upper quadrant in the transverse
orientation. Ensure that bowel is identified before the probe is moved.
Clinical Pearl:
Bowel gas may scatter the image, making for a challenging scan. Light
sedation can make the POCUS more comfortable for the patient and allow
the POCUS physician to clear some bowel gas by pushing down harder on
the abdomen.
For more on Pediatric Procedural Sedation, go to Chapter 5
139
Q: After identifying the bowel and adjusting for the correct

depth, what are the next steps?
A: Scan the entire bowel in the transverse orientation. Once all the bowel
is seen, rotate the probe into the longitudinal position to once again
visualize all the bowel. This should be repeated in all the other abdominal
quadrants.
Q: You've visualized the bowel in all four quadrants. Is this a

satisfactory stopping point, or are other areas necessary to
visualize?
A: Looking in just the four quadrants is not sufficient. It is important to look

along the flank, in the paracolic gutter (slightly lower than standard FAST
view) to ensure all the areas of possible intussusception are covered. Once
all these areas are visualized, the POCUS is complete.
Step-by-Step Approach to Intussusception POCUS
1. Using the linear probe, start in RUQ

2. Set depth at 6 cm to 8 cm
3. Scan transversely making sure to visualize all the bowel
4. Flip probe to longitudinal orientation and repeat scan
5. Apply same steps for each abdominal quadrant
6. Finally, look along the flank, in the paracolic gutter (slightly lower than
standard FAST view)
140
Q: Great! And what will help you determine if the patient does in fact
have intussusception?
A: Look for the target sign or doughnut sign (mmm … delicious). A target sign can
be found in appendicitis, intussusception, and pyloric stenosis. In the transverse
view you can see one ring within another. In the longitudinal view it may have a
layered appearance of bowel stacked onto itself.
Video: Dr. Samuel Lam illustrates the technique of POCUS for intussusception in the
following video.
FOAMed Link: For an interesting case of Intussusception picked up by POCUS on the

EDE blog, click here.
Clinical Pearl:
Before diagnosing intussusception, ensure that you have seen it in both

planes (transverse and longitudinal).
141
Comments?

this podcast.
KEY REFERENCES:
1. Sivitz AB, Cohen SG, Tejani C. Evaluation of acute appendicitis by pediatric emergency physician
sonography. Ann Emerg Med. 2014; Oct;64(4):358-364.
2. Elikashvilli I, Tay ET, Tsung JW. The effect of point of care ultrasound on emergency department
length of stay and computed tomography utilization in children with suspected appendicitis. Acad
Emerg Med. 2014; Feb;21(2):163-170.
3. Pineda C, Hardasmalani M. Pediatric intussusception: A Case Series and Literature Review.
Internet J Pediatrics and Neonatology. 2008; 11(1):1-7.
142
CHAPTER 10:
GASTROENTERITIS,
CONSTIPATION & OBSTRUCTION
LISTEN TO THE PODCAST WITH ANNA JARVIS AND STEPHEN FREEDMAN HERE
Objectives
1. Develop an approach to assessing the child with vomiting and diarrhea
2. Review the management of gastroenteritis
3. Develop an approach to treating functional constipation
4. Understand the pathophysiology of intussusception
5. Describe an approach to the management of intussusception
6. Develop an approach to imaging investigations for pediatric patients with abdominal pain
7. Identify children at risk for mid-gut volvulus
8. Be able to distinguish surgical causes of abdominal pain from sickle cell pain crisis
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CASE 1:
VOMITING & DIARRHEA
A seven-year-old boy presents to your ED at 9 p.m.
with a history of diarrhea and fever for two days, as
well as vague abdominal pain. On further questioning,
he has no travel history, his immunizations are up to
date, there are no known infectious contacts, and he
is otherwise healthy on no medications. He vomited
once that morning, has no urinary symptoms, no
URI symptoms, and no rash. On exam, his vital signs
are normal except for a temperature of 38.1oC. His
abdomen is soft, with slight diffuse tenderness, and
no peritoneal signs.
Q: What is your differential diagnosis in this

case?
A: As every clinician knows, gastroenteritis is a very

common diagnosis for pediatric patients presenting with
vomiting and diarrhea. Fortunately, in most cases it has Key diagnoses to consider
a self-limited and relatively benign course. However, the before making a diagnosis
challenge is being able to accurately distinguish it from of gastroenteritis:
more serious illnesses that can present with similar
symptoms. At present, there is no simple means to •• Intracranial mass
definitively rule in gastroenteritis. Therefore, it should •• Meningitis
be considered a diagnosis of exclusion. •• Intussusception
•• Diabetic ketoacidosis
•• Cholinergic syndrome
Clinical Pearl: •• Pneumonia
•• Myocarditis
Vomiting in the absence of diarrhea, especially •• Appendicitis
persistent vomiting, should elevate a clinician’s •• Urinary tract infection
suspicion of a more serious alternative
diagnoses other than gastroenteritis.
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Q: What are the key aspects of the history when assessing a child who
presents with vomiting and diarrhea?
A: It is important to ask about exposure to sick contacts, such as daycare or siblings.

In addition, assess for potential risk of either bacterial or parasitic infections by asking
about the patient’s AND family’s recent travel history, antibiotic use, exposure to
untreated water or unpasteurized dairy products, and consumption of undercooked or
raw meats.
A history of chronic or recurrent episodes of diarrhea can be suggestive of

inflammatory bowel disease and require further workup after discharge from the ED.
Case continued: Based on the history and physical exam, you determine the
most likely diagnosis is gastroenteritis and proceed to assess the child for signs of
dehydration.
Q: What are the most useful signs for

assessing for dehydration?
A: Both parental reports and clinician gestalt are

surprisingly sensitive for identifying dehydration.
However, they are both prone to overestimating
the severity, and therefore can lead to excessively The Gorelick Score
aggressive measures of rehydration.
Two or more of the
The three most useful clinical exam findings for following suggests > 5%
detecting > 5% dehydration in a child are: prolonged dehydration:
capillary refill, abnormal skin turgour, and abnormal •• Capillary refill > two
respiration patterns. seconds
•• Absent tears
Two clinical decision rules, which can be used •• Dry mucous membranes
together or on their own, have been shown to •• Ill general appearance
perform better than any single physical exam
finding. These are the Gorelick Score and the Clinical
Dehydration Scale.
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Clinical Dehydration Scale
0=No dehydration 1–4 =Some dehydration 5–8=Moderate/severe dehydration
*Goldman RN, Friedman JN, Parkin PC. Validation of the Clinical Dehydration Scale for children with acute
gastroenteritis. Pediatrics. 2008; 122 (3): 545-549
For practical purposes to direct management, we recommend the

following classification for dehydration:
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Q: As you consider your next steps for this patient,

you cringe at the thought of having to poke the
child for blood. What is the role for laboratory
investigations in the context of a child with
presumed gastroenteritis?
A: Most children do NOT require investigations. Situations

where investigations could be helpful would include a
capillary glucose when a child appears lethargic to detect
hypoglycemia, a urinalysis in the presence of polyuria or
polydipsia to screen for DKA or in children with fever or prior
urinary tract infections to screen for another infection.
Electrolyte abnormalities are usually minor and rarely affect

management. A serum bicarbonate of > 15 mEq/l reduces
the likelihood of dehydration. However, if you are planning
to start IV rehydration, ordering baseline electrolytes are
important to monitor for iatrogenic electrolyte derangements.
Q: After telling your resident that this patient does

not require blood work, she asks, “Doesn’t this patient Clinical Pearl:
require blood work to rule out hemolytic uremic Hemolytic uremic
syndrome?” syndrome may occur
after the diarrhea has
A: A complete blood count and creatinine should be ordered if resolved.
there is clinical concern for hemolytic uremic syndrome (HUS).
HUS is a bacterial enteritis most commonly caused by

the Shiga toxin produced by E. Coli 0157:H7 that results
in a classic triad of microangiopathic hemolytic anemia, Caution:
thrombocytopenia, and renal insufficiency.
Do not give antibiotics
Clinical features that should raise suspicion for HUS include empirically to patients
patients presenting with bloody stool and abdominal pain, at risk for HUS, as it
lethargy, low-grade fever, paleness and tachycardia, petechia, may exacerbate the
periorbital edema (especially upon waking), and tea-coloured disease.
urine.
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Q: Your resident then asks, “What about a stool culture?” What are the
indications for obtaining a stool culture for patients presenting with
diarrhea?
A: The indications for obtaining a stool culture are any of the following: travel to
an endemic country, > 10 diarrhea stools in 24 hours, > five days duration and not
resolving, blood and/or mucous in stools, and unremitting fever.
On further assessment to determine the child’s hydration, you note that he is

irritable, with dry mucous membranes and decreased tears. You calculate his Clinical
Dehydration Scale to be 3, suggestive of “some” dehydration being present.
Q: How would you rehydrate this child with some signs of dehydration
from gastroenteritis?
A: Oral rehydration is the treatment of choice for children with acute gastroenteritis
who have evidence of some dehydration. Compared with IV rehydration, oral
rehydration therapy is associated with a lower risk of complications such as
electrolyte imbalances, cerebral edema, phlebitis, and cellulitis.
Oral rehydration solution dose: The following does are administered via syringe,
preferably by the parents, q5min, for a goal of 30 ml (1oz)/kg/hour for the first three
to four hours:
•• 5 cc if < six months old
•• 10 cc if six months to three years old
•• 15 cc if > three years old
•• An additional 10 cc/kg/stool should be administered for
each episode of diarrhea in the ED
•• The child should continue to breastfeed during this time
Start slow in the first 30 to 60 minutes to minimize the chance of emesis

and obtain buy-in from the parents and patient.
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Q: You’d like to give your oral rehydration

treatment it’s best shot. What is the role for Pitfall:
oral ondansetron for treating vomiting in acute
gastroenteritis? Do NOT use ondansetron
as a diagnostic test based
A: Compared with placebo, oral ondansetron stops on response to treatment.
vomiting more frequently (NNT 5), prevents IV insertion If a child stops vomiting
(NNT 5), and reduces immediate admission rates without after taking ondansetron,
masking serious disease or leading to worse outcomes. it does NOT rule out
Studies suggest there is no change in hospitalizations alternate diagnoses such
at 72 hours, as ondansetron does not alter the disease as appendicitis.
trajectory, and patients with more severe illness can still
return to hospital.
Oral ondansetron is dosed according to the child’s weight: Caution:
Children from 8 kg to 15 kg 2 mg Ondansetron may

Children 15kg to 30 kg 4 mg prolong the QTc
Children over 30 kg 8 mg interval. Do not use
ondansetron in patients
Ondansetron should be given as a single dose. A repeat with known prolonged
dose can be considered if the child vomits within 15 QTc, hypokalemia or
minutes of getting the initial dose. Keep children NPO for hypomagnesemia,
15 minutes before starting oral rehydration therapy to congenital heart
allow the medication time to take effect. disease, or CHF.
We suggest that ED physicians do not provide a prescription for ondansetron for

outpatient management of vomiting associated with gastroentritis. There is no
evidence of any benefit for this strategy, and repeat dosing has been shown to
increase diarrhea. Prescribing ondansetron may also deter parents from bringing
their child back for reassessment if the child experiences worsening symptoms.
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Q: The child tolerates the oral Q: After receiving the discharge

rehydration therapy with instructions, the parents ask if their
Pedialyte after receiving a child needs antibiotics or antidiarrheal
single dose of ondansetron, medication. Are antidiarrheal medications
and appears well enough to be or antibiotics recommended for the
discharged upon reassessment. treatment of acute gastroenteritis?
What are your typical discharge
instructions for patients with A: Antibiotics are rarely indicated, even for
acute gastroenteritis? bacterial pathogens among immunocompetent
patients. Consider using antibiotics when
A: The child should resume a regular a child is persistently ill and high-risk (i.e.,
diet as early as possible and avoid immunocompromised, sickle cell disease,
drinks high in sugar, as they can corticosteroid use, or recent chemotherapy),
worsen the diarrhea. or are older than one year of age and have
risk factors for a Clostridium difficile infection
There is some literature to suggest (i.e., recent hospitalizations, recent antibiotic
that the early initiation of a regular use, history of inflammatory bowel disease, or
diet including solid food shortens immunocomprised).
the duration of diarrhea in children
with gastroenteritis. There is no With respect to antidiarrheal agents, neither
evidence to show benefit of using loperamide nor bismuth should be used in the
the BRAT (bananas, rice, apple sauce, treatment of acute pediatric gastroenteritis.
and toast) diet over a regular diet, Loperamide may cause lethargy or paralytic
and there is no role for ongoing use ileus. Alarmingly, there have also been case
of oral rehydration solution or fluid- reports of death attributed to the use of
only diet after the patient has been loperamide. Bismuth is also not recommended
rehydrated in the ED. as it may lead to salicylate toxicity.
The child should return to the ED for On the other hand, there is some evidence to
reassessment if they develop bloody suggest that probiotics may shorten the duration
diarrhea, worsening abdominal pain, of diarrheal illnesses and have a far more
increased vomiting, are unable to favourable safety profile. However, they should
tolerate fluids, or develop lethargy. be avoided in children with indwelling lines,
congenital heart disease, or short gut syndrome.
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CASE 2:
BLOATED
A two-year-old girl presents at 9 p.m. to your ED with several hours of
intermittent crying and looking “bloated.” There is no history of vomiting,
fever, or urinary symptoms, and the last bowel movement two days ago
was normal. Last week, she had a mild upper respiratory tract infection
that resolved spontaneously. She is otherwise healthy with no past
medical or surgical history, and is taking no medications. On exam,
the vital signs are normal except for a slightly high heart rate and a
temperature of 38.0oC. The abdomen is soft and non-tender, and bowel
sounds are present. An abdominal X-ray shows a moderate amount of
fecal loading and no obvious signs of obstruction. The girl is diagnosed
with constipation, and discharged home with a script for lactulose and
dietary instructions.
Q: How is pediatric functional constipation defined? How do you

make the diagnosis in the ED?
A: Functional constipation is the most common cause of abdominal pain in

children, but should still remain a diagnosis of exclusion.
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The most widely accepted definition for functional constipation are the
Rome III criteria. There are two sets of criteria, one for children who have
a developmental age younger than four years of age, and another for
children with a developmental age of four years or older.
The Rome III Diagnostic Criteria for Functional Constipation
In the absence of organic pathology, at least two of the following must occur for
one month for a child with a developmental age < four, and at least once a week
for two months for a child with a developmental age of ≥ four.
1. Two or fewerdefecations per week
2. At least one episode of fecal incontinence per week after the acquisition of
toilet training skills
3. History of excessive stool retention or retentive posturing
4. History of painful or hard bowel movements
5. Presence of a large fecal mass in the rectum
6. History of large-diameter stools that may obstruct the toilet
Q: What are some red flags that should alert a physician to

consider diagnoses other than functional constipation?
A: Some red flags on history that are suggestive of more serious diseases
include a history of fever, abdominal distention, anorexia, nausea or
vomiting, weight loss, delay in first bowel movement for more than 48
hours after birth, and blood in the stools.
On physical exam, the astute clinician should also note the absence of stool
in the rectum on digital rectal exam in the presence of a large palpable
fecal mass in the abdomen, abdominal distension, and evidence of lower
back skin defects.
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Clincal Pearl:
Diseases to consider in the child with constipation:

•• Hirschsprung’s disease: Presents as severe obstipation with overflow
diarrhea and abdominal distension in a non-thriving, fussy child; it can
also present as toxic megacolon
•• Hypothyroidism and cystic fibrosis: Assess family history and whether
family members were screened
•• Down syndrome
•• Myelomelingocele or neuromuscular diseases: Can present with
history of a delay to walking or unusual gait
•• Celiac disease: May have a family history
•• Child abuse
Q: You are now more sure that this is functional constipation.

How do you treat functional constipation?
A: Oral medications work better when combined with enemas in the ER.
After initiating treatment, it is important to explain to parents that it can
take months to years to retrain the bowel.
For enemas, if the child is younger than two years old, use a saline enema
at 20 cc/kg. Children > 20 kg can use an adult fleet enema.
Upon discharge home, patients should be instructed to take PEG 3350 (e.g.,
Laxaday) at a dose of 1–1.5 g/kg/day dissolved in 240 ml of fruit juice until
the child has one soft stool per day for three days, and then titrate down
the dose. PEG 3350 is preferred over lactulose.
Q: Are there any dietary or lifestyle recommendations that can

help to improve functional constipation?
A: Infants four to eight months of age are advised to add 120 ml of fruit
juice to their diet, substitute barley cereal in place of rice cereal, and use
glycerine suppositories as needed.
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Older children can be advised to increase their intake of fluids and fibre
(e.g., bran cereals, fruits such as pears or prunes, and beans).
Children can also supplement with a daily powdered fibre such as

Metamucil (¼ tsp if younger than six years old, ½ tsp for children six to 12,
and 1 tsp for children older than 12 years) taken with a large cup of water.
With respect to behaviour modifications, parents should promote

unhurried toilet time after meals and track activity with a stool diary.
Case continued: The next day, the family returns to the ED and the child
looks lethargic, pale, and tachypneic, with a distended abdomen. The girl
is placed on a monitor and an IV is started in the resuscitation room. A
20 cc/kg NS bolus is given, as well as IV antibiotics to cover for possible
sepsis. A portable abdominal X-ray is ordered and blood work is sent.
The X-ray shows prominent loops of bowel. A venous blood gas comes
back showing a metabolic acidosis with pH of 7.1. A rectal examination
is done with a positive fecal occult blood test. The patient was stabilized
and sent for advanced imaging.
Q: What diagnosis is at the top of your differential now?
A: Intussusception.
Q: What is the typical presentation for intussusception?
A: Intussusception predominantly occurs in children younger than

two years of age, and is unlikely to occur after the age of seven. It can
often occur during viral gastroenteritis outbreaks, as inflamed enlarged
Peyer’s patches within the intestinal wall can act as a lead point for the
intussusception to occur.
There are two common and classic presentations for intussusception:

1. Vomiting with severe paroxysmal episodes of abdominal pain
2. The listless, lethargic infant
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The abdominal presentation may manifest as severe

crying epsisodes (as in this illustrative case) lasting one
to five minutes, separated by pain-free intervals of
Clincal Pearl: three to 30 minutes in duration during which the child
may actually appear either tired and drowsy or return
Parents sometimes to normal activities. This cyclic pattern occurs as the
describe the child as peristaltic wave encounters the intussusception region.
pale and sleepy in The vomitus is usually non-bilious since the obstruction is
between episodes of typically distal in the ileocecal region.
paroxysmal pain.
The classic triad of intussusception consists of colicky
intermittent abdominal pain, vomiting, and “currant
jelly stools.” However, as with all “classic triads,” this
constellation occurs relatively infrequently, accounting
for only 10% to 20% of documented cases.
Clincal Pearl: Typically, the episodes of pain will intensify and increase
in duration with shorter pain-free intervals. Vomiting
“Currant jelly stools” usually develops within the first six to 12 hours.
are a late finding in
intussusception, and Q: You make the diagnosis of intussusception
are often absent on and the parents ask you what may have
initial presentation to caused this. You also begin to consider causes
the ED. The absence of intussusception and wonder about other
of currant jelly diagnoses not to miss in this patient. What
stools should not diagnosis should you consider?
dissuade a clinician
from a diagnosis of A: Henoch-Schonlein purpura (HSP) is frequently
intussusception. implicated as a potential cause for intussusception.
HSP is a vasculitis that affects children predominantly
between the ages of two to 11 years old. It is classically
characterized by the triad of abdominal pain, arthritis,
and palpable purpura.
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The abdominal pain is typically diffuse and colicky, and may precede the
rash, making the diagnosis more difficult. The arthritis is migratory, usually
targeting the knees and ankles, and associated with periarticular swelling
and redness on exam. The palpable purpuric rash is the hallmark of HSP.
It usually is isolated to the buttocks and lower extremities and may look
urticarial or petechial.
Other findings associated with HSP include hematuria and proteinuria,

recent viral illness, scrotal edema, and history of bloody stools.
About 5% of cases of HSP will present as intussusception, where areas of

bowel edema secondary to the vasculitis serve as a lead point.
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The International Consensus Conference Diagnostic

Criteria for HSP
Palpable purpura in the presence of one or more of the following:
•• Diffuse abdominal pain
•• Any biopsy showing predominant IgA deposition
•• Arthritis or arthralgias
•• Renal involvement (hematuria or proteinuria)
Clincal Pearl: Caution:
Atypical presentations of intussusception A recent viral

include: illness can be a
•• Older children with intermittent abdominal precipitating factor
cramping and no vomiting for intussusception.
•• Vomiting in the absence of abdominal pain Therefore, DON’T
•• Very early presentations of vomiting that attribute a child’s
resemble gastroenteritis abdominal pain to
•• Infants that present with lethargy or seizures their recent viral illness
suspicious for CNS disease or sepsis before considering
•• Patients presenting with hematemesis intussusception.
Q: What should you be looking for on physical exam for the patient
with suspected intussusception?
A: The patient may appear pale and lethargic in between episodes, and show
signs of dehydration such as a prolonged capillary refill, abnormal respirations
or dry mucous membranes.
However, the exam between episodes of abdominal pain can also be relatively
unremarkable. A well-appearing child with a good history for intussusception
warrants further observation in the ED.
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Pitfall:
A common pitfall is assuming that a well-appearing child cannot have

intussusception. A well-appearing child in the ED can certainly still have an
intussusception, as you may be assessing them in between the paroxysms of
pain, crying, or vomiting.
A sausage-shaped abdominal mass can sometimes be palpated in the RUQ. This

sausage mass can best be palpated in those who have very soft abdomens. In
most infants and children with intussusception, the abdomen is very soft once the
painful cycle has passed, facilitating the palpation of the mass.
Experienced clinicians who have examined many children may be able to detect
a subtle emptiness in the RLQ (known as “dance sign”), with the intussuscepted
segment of bowel migrating up to the RUQ.
While the utility of a rectal examination for most cases of pediatric abdominal pain
has been called into question, the presence of fecal occult blood can be an early
clue for intussusception well before the onset of currant jelly stools.
The remainder of the exam should focus on ruling out alternative diagnoses that
can present in a similar manner, such as an inguinal hernia, testicular torsion,
midgut volvulus, sepsis, meningitis, or non-accidental trauma.
Q: Should you order any further investigations? What role does plain
radiography serve in diagnosing intussusception?
A: Although plain film radiographs of the abdomen have poor sensitivity, there are
a number of potential findings that can be highly suggestive of intussusception.
It is estimated that up to 25% of abdominal plain films are normal in patients
who have a final diagnosis of intussusception. However, subtle findings such as a
target sign or crescent sign can warrant consultation with a surgeon (see images
on following pages). In addition, plain films can be used to screen for potential
complications such as perforated viscous or evidence of a small bowel obstruction.
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Clincal Pearl:
The “big three” findings to look for on EVERY pediatric plain film of the abdomen:
•• Free air to detect perforated viscous
•• Multiple air fluid levels to detect small bowel obstruction
•• The double bubble sign to detect proximal obstructions such as volvulus
Three plain film signs specific to intussusception:
The target sign is a faint, doughnut-shaped mass in the right upper quadrant; it is subtle, so
you must specifically be looking for it, and its presence is near diagnostic of intussusception.
An example of the subtle yet fairly specific sign of intussusception

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The crescent sign occurs because the leading point of

the intussusception (intussusceptum) protrudes into
a gas-filled pocket. When this occurs, a crescent shape
may result and is highly indicative of intussusception. If there is evidence of a
The shape of the crescent will always be in the bowel obstruction on a
direction of transit through the colon (i.e., upward pediatric X-ray, use the
in the ascending colon, right to left in the transverse mnemonic “Double A-I-M”
colon, and downward in the descending colon). to generate a differential
for the underlying
etiologies:
•• Adhesions
•• Appendicitis
•• Intussusception
•• Incarcerated hernia
•• Malrotation/volvulus
•• Meckel’s diverticulum
Crescent sign seen in intussusception
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Q: All this considered, what is your diagnostic test of choice for

intussusception?
A: Ultrasound is regarded by many as the best test for diagnosing

intussusception, with near 99% sensitivity, and it is less invasive than a
contrast enema study. Similar to X-ray, ultrasound can identify a target sign
(a hypoechoic ring with a hyperechoic centre). It can also often identify the
leading edge along with Doppler flow studies to detect ischemic segments
of bowel, to assist with surgical planning.
Target sign of intussusception on ultrasound
For more on POCUS for intussusception, jump to Chapter 9.
Case continued: The ultrasound was positive for intussusception.

The surgeon was consulted, and she opted not to do an air-contrast
enema, and instead took the patient to the operating room, where she
found perforated bowel and intestinal ischemia. The patient had a long
postoperative recovery, but ended up doing well.
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Q: Contrast enema studies have the dual benefit of being

potentially both diagnostic and therapeutic for intussusception.
What are potential contraindications for contrast enema studies?
A: An enema can perforate the bowel if the gut is ischemic. Gastrografin has a
high osmolality and can produce shock (secondary to intravascular depletion)
in the case of perforation. Some centres prefer air-contrast enemas since
they result in smaller tears in the event of perforation. Using air is also less
expensive, requires less radiation, and leads to shorter fluoroscopy times.
Contraindications for performing a contrast enema include:

•• Suspected or confirmed perforation
•• Symptoms lasting longer than 24 hours
•• Evidence of obstruction
•• Intestinal ischemia
CASE 3:
OBSTRUCTED
A five-year-old boy is brought to the ED with a chief complaint of diffuse
abdominal pain and persistent vomiting for the past 24 hours. He has not
tolerated oral fluids at home. His last bowel movement was two days ago
and his last urination was 12 hours ago. He has no fever, diarrhea, dysuria,
or coughing. His past history is significant for two previous episodes of
severe abdominal pain, which resolved on their own.
On exam his vital signs were normal: heart rate 100, respiratory rate
30, blood pressure 110/70. He is moderately ill appearing; pale with dry
mucous membranes and diminished skin turgour. His abdomen is soft and
slightly tender all over. Bowel sounds are diminished. He has no inguinal
hernias and his genitals are normal.
An abdominal X-ray is done that shows findings of an obstruction,

suspicious for midgut volvulus.
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Q: What is volvulus, and how does it occur?
A: The mesentery is suspended by a stalk containing its own vascular

supply. In midgut volvulus, the entire stalk can twist on itself, leading to life-
threatening ischemia of the entire small bowel. Midgut volvulus has a high
mortality rate when it is not surgically corrected in a timely manner.
Children born with congenital malrotation are at high risk for midgut
volvulus. Roughly half of those born with malrotation will manifest with an
acute bowel obstruction during the first few months of life.
Q: The early diagnosis and treatment of midgut volvulus is

essential to avoid catastrophe. When should a clinician consider
midgut volvulus?
A: A clinician should be extra vigilant to identify midgut volvulus with any

neonate presenting with a sudden onset of bilious vomiting, abdominal
pain, or distension.
Clinical Pearl:
Pitfall:
Be sure to also consider Any infant presenting with

midgut volvulus in any child bilious vomiting should be
who appears septic from considered to have midgut
a presumed abdominal volvulus until proven
source. otherwise.
Q: How do you make the diagnosis of midgut volvulus?
A: Plain film x-rays of the abdomen can show evidence of a proximal bowel
obstruction, also known as the double bubble sign, with one bubble in the
stomach and one in the duodenum.
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Double bubble sign in midgut volvulus
164
Ultrasound is not nearly as definitive as it is for intussusception, but it can

be suggestive of the diagnosis. The most specific finding is the presence
of the superior mesenteric artery on the right (opposite) side of the
mesenteric vein. It is important to note that a negative ultrasound doses
not rule out midgut volvulus.
The gold-standard test for midgut volvulus is an upper GI series under

fluoroscopy. This will allow definitive visualization of the small intestine
rotated on the right side of the abdomen.
Case continued: You receive a verbal report that the child’s ultrasound
is very suggestive of midgut volvulus. Seconds later, the nurse calls you
STAT to the child’s bedside. The child is now tachycardic with a heart
rate of 200 bpm, and the blood pressure is 60 mmHg on palpation. She
appears very lethargic and unwell.
Q: What treatments need to be initiated immediately in the ED

for this patient?
A: This child requires aggressive fluid resuscitation, with a minimum of two

20 cc/kg boluses of normal saline. Broad spectrum antibiotics should be
initiated that cover Gram-positive, Gram-negative, and anaerobic organisms
(e.g., ampicillin, gentamicin, and clindamycin). Surgery should be consulted
in parallel with the implementation of these treatments.
CASE 4:
PMHx SICKLE CELL DISEASE
An adolescent female with a history of sickle cell disease presents
with nausea, vomiting, and poorly localized abdominal pain that has
prevented her from attending school. She is adamant that this feels
different than her previous vaso-occlusive pain crisis. She denies
any chest pain, back pain, or arthralgias. She is afebrile and slightly
tachycardic, with a heart rate of 105 bpm. Her blood pressure is 110/75.
She appears uncomfortable on exam and is noted to have tenderness in
the RUQ. She has no prior surgeries.
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Q: How can a clinician distinguish a sickle cell pain crisis from a surgical
abdomen?
A: Unfortunately, a vaso-occlusive pain crisis can perfectly mimic a surgical abdomen, with
patients presenting with symptoms of nausea, vomiting, fever, and peritoneal tenderness.
Leukocytosis is a near universal finding, and of virtually no discriminatory value.
Although very little evidence exists in the literature, many experienced clinicians will report
that if the pain is reported to be similar to a previous pain crisis, an underlying surgical
etiology is less likely.
In contrast, pain that occurs in the absence of typical bone or joint symptoms is more likely
to be associated with a problem requiring surgery.
Clincal Pearl: High-Yield Associations and Pearls in

Pediatric Abdominal Pain
•• Intermittent pain with a change in stools (esp. bloody) ==> Intussusception

•• Neonate with bilious vomiting ==> Midgut volvulus
•• Scrotal swelling or discolouration ==> Testicular torsion
•• Polyuria and polydipsia ==> DKA
•• Recent mononucleosis ==> Splenic rupture
•• Petechial rash on buttocks and legs ==> Henoch-Schonlein purpura
•• Hematuria and proteinuria ==> Henoch-Schonlein purpura
•• Sterile pyuria ==> Appendicitis
•• Glucosuria and ketonuria ==> DKA
•• Occult blood in stool ==> Intussusception or midgut volvulus
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KEY REFERENCES:
1. Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated? JAMA. 2004; Jun;291(22):27-46.
2. Freedman SB, Vandermeer B, Milne A, Hartling L, Pediatric Emergency Research Canada
Gastroenteritis Study Group. Diagnosing clinically significant dehydration in children with acute
gastroenteritis using noninvasive methods: a meta-analysis. J Pediatr. 2015; Apr;166(4):908-916.
3. Friedman JN, Goldman RD, Srivastava R, Parkin PC. Development of a clinical dehydration scale
for use in children between 1 and 36 months of age. J Pediatr. 2004; Aug;145(2):201-7.
4. Gorelick MH, Shaw KN, Murphy KO. Validity and reliability of clinical signs in the diagnosis of
dehydration in children. Pediatrics. 1997; May;99(5).
5. Freedman SB, Adler M, Seshadri R, Powell EC. Oral ondansetron for gastroenteritis in a pediatric
emergency department. N Engl J Med. 2006; Apr;354(16):1698-705.
6. Fedorowicz Z, Jagannath VA, Carter B. Antiemetics for reducing vomiting related to acute
gastroenteritis in children and adolescents. Cochrane Database Syst Rev. 2011; Issue 9.
7. Bernaola Aponte G, Bada Mancilla CA, Carreazo NY, Royas Galarza RA. Probiotics for treating
persistent diarrhea in children. Cochrane Database Syst Rev. 2013; Issue 8.
8. Goldenberg JZ, Lytvyn I, Steurich J, Parkin P, Mahant S, Johnston BC. Probiotics for the prevention
of the pediatric antibiotic-associated diarrhea. Cochrane Database Syst Rev. 2015; Issue 12.
9. Hymen PE, Milla PJ, Benninga MA, Davidson GP, Fleisher DF, Taminiau J. Childhood functional
gastrointestinal disorders: neonate/toddler. Gastroenterology. 2006; Apr;130(5):1519-26.
10. Rasquin A, Di Lorenzo C, Forbes D, et al. Childhood functional gastrointestinal disorders: child/
adolescent. Gastroenterology. 2006; Apr;130(5):1527-37.
11. Dillon MJ, Ozen S. A new international classification of childhood vasculitis. Pediatr Nephrol. 2006;
Sep;21(9):1219-22.
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167
CHAPTER 11:
DIABETIC KETOACIDOSIS
LISTEN TO THE PODCAST WITH SARAH REID AND SARAH CURTIS HERE
Objectives
1. Identify aspects of the history and physical exam that should prompt one to suspect
DKA in children
2. Develop an understanding of the diagnostic criteria for DKA and how this directs
investigations in whom the diagnosis is suspected
3. Develop an approach to the management of DKA based on disease severity
4. Understand the risk factors and clinical presentation of cerebral edema in DKA patients
5. Develop an approach to the management of cerebral edema in DKA patients
168
CASE 1:
APPROACH TO DIABETIC KETOACIDOSIS
(DKA)
A four-year-old boy presents to your academic ED with his parents
complaining of abdominal pain and shortness of breath since waking
that morning. They report a low-grade fever two days ago, which has now
resolved, no vomiting, and normal bowel movements. He has had a mild
cough for three days but no chest pain. They report that he’s been going to
the bathroom more often than usual to urinate. His past medical history is
unremarkable.
On exam he appears fatigued but is alert and oriented with a GCS of 15.
He is tachypneic with deep respirations but no indrawing. The patient has a
clear chest, capillary refill is two seconds, and mucous membranes are dry.
Abdominal exam is benign and the neurological exam is grossly normal.
Q: Yes, this is a DKA chapter, so the diagnosis is DKA. However, this

case describes very non-specific symptoms, which may not trigger
a consideration of DKA. What are some of the clues in this case that
should trigger one to consider DKA?
A: Most patients will not present with the classic constellation of polyuria,
polydipsia, nausea/vomiting, and abdominal pain. The presence of
tachypnea with a clear chest should prompt the consideration of acidosis.
Hyperventilation is an attempt to release CO2 from the blood as a respiratory
compensation for the metabolic acidosis associated with DKA. This breathing
pattern is called Kussmaul breathing.
Polyuria on history should prompt the consideration of three diagnoses in

pediatric patients: urinary tract infection, hyperglycemia, and hypercalcemia.
Abdominal pain without associated gastrointestinal symptoms (or with isolated
vomiting) should prompt consideration of DKA. Consider this diagnosis in any
child with altered mental status, and remember that “glucose is the sixth vital
sign!”
169
Q: You suspect the diagnosis of Q: Your student on shift asks, “Why

DKA in this child. You know it do kids with DKA get so sick? And
is also important to assess for why do they look so dehydrated?” An
an underlying trigger for this understanding of the pathophysiology of
episode of DKA. What are the DKA helps to understand the management
common triggers for DKA? strategies. What are the underlying
metabolic derangements in DKA?
A: Underlying viral or bacterial
infection are common triggers for A: DKA is most commonly seen in patients with
DKA. This four-year-old boy had a type 1 diabetes since the disease is defined by
mild cough and fever, which likely insulin deficiency. The lack of insulin prevents
triggered his DKA presentation. In glucose from entering the cells of the body and
patients with known diabetes, high- being used as an energy source. Stress hormones
risk groups for DKA are those with are released due to the body’s perceived energy
a prior history of DKA, peri-pubertal supply deficiency. This causes further glucose
and adolescent girls, and those on release from glycogen stores as well as the
insulin pumps. Adolescent girls may breakdown of free fatty acids into a usable
reduce insulin use in an attempt energy source. Fatty acid breakdown leads to the
to lose weight, which predisposes formation of keto-acids, which accumulate in the
to DKA. In patients with known blood and cause acidosis. The accumulation of
diabetes, always assess for insulin glucose in the blood eventually overwhelms the
adherence and inquire regarding ability of the kidney to reabsorb glucose, causing
missed insulin doses. loss of glucose in the urine and resulting osmotic
diuresis and dehydration.
Q: Given the pathophysiology underlying DKA, what are the criteria we use
to diagnosis it?
A: The diagnosis of DKA requires the presence of acidosis, ketosis, and hyperglycemia.
Diagnostic Criteria for DKA
170
Q: Given these diagnostic criteria, what tests will

you order for this child with suspected DKA? Clinical Pearl:
A: Once a capillary glucose is obtained and DKA is Acidosis determined

suspected, initial investigations would include CBC, from a venous blood gas
electrolytes, BUN, creatinine, urinalysis, and a VBG. If (VBG) is just as useful
the patient is hypokalemic or hyperkalemic, an ECG in the management of
is warranted. Other investigations can be directed at DKA as an arterial blood
finding an underlying trigger for DKA, such as a chest gas (ABG) in pediatric
X-ray if pneumonia is suspected, for example. patients. Save the patient
the difficult poke of an
A urinalysis to detect the presence ABG and just use the VBG.
of ketones (as apposed to serum
ketones) is adequate in the vast majority of pediatric
patients for the detection of ketosis in DKA. While the
sensitivity of urine ketones may be less than serum
ketones early in the disease course, clinical experience
of our experts suggests the urine ketones are rarely
negative in DKA. In patients with elevated glucose and
osmolality but negative urine ketones, you can consider
the diagnosis of hyperglycemic hyperosmotic syndrome
(HHS). However, this is very rare in pediatric patients, as
this is usually associated with type 2 diabetes. Like any
test, it needs to be interpreted in light of your pretest
probability. If urine ketones are negative and you have
a high index of suspicion for DKA, this warrants further
testing with serum ketones or a VBG.
Q: The child in this case appears to be quite sick.

The management of the child will depend on the
severity of disease. How do you determine the
severity of the DKA?
A: The severity of DKA is classified based on the degree

of acidosis and the HCO3 level.
171
Q: You are working in an academic hospital that sees adult patients almost
exclusively, and so you are more familiar with managing DKA in adults.
In general, how does the management of DKA differ between adults and
pediatric patients?
A: The key goals in managing DKA are to correct hypovolemia, correct acidosis, reverse
ketosis, restore glucose to near normal, monitor for complications, and treat any
precipitating event. While these principles are true both in adult and pediatric populations,
there are major differences in management between adults and pediatric patients.
1. IV fluids: While adult DKA guidelines recommend multiple fluid boluses in the
first two hours of care, fluid boluses are indicated only in pediatric patients who
are in decompensated shock. Judicious use of IV fluids is encouraged with twice
maintenance being the upper limit of the rate of administration.
2. Potassium management: Adult DKA patients have strict potassium cut-offs that
guide insulin administration, but potassium management in pediatric DKA is less
stringent. This is because pediatric patients are less prone to arrhythmias with
hypokalemia.
3. Sodium bicarbonate: While sodium bicarbonate is recommended in adult DKA with
a pH < 7.1, its use in pediatric DKA is limited to patients with cardiovascular collapse.
Case continued: The four-year-old boy in this case is hyperventilating. Clinically he

looks mildly hypovolemic but is tolerating oral intake. Investigations are remarkable
for a glucose of 22 mmol/l, pH of 7.25, and a HCO3 of 14 mmol/l.
Q: How would you manage this patient?

All DKA patients
A: This child has mild DKA. Mild DKA patients can usually be should be
managed with subcutaneous insulin in the ED. If they are able to
managed in
tolerate oral fluids, they can often be treated as outpatients with
consultation with
subcutaneous insulin following a period of observation and close
a pediatrician
follow-up in a diabetes clinic the next day.
or pediatric
endocrinologist.
Children younger than five years of age will generally be admitted,
as they are at higher risk for decompensating. Insulin titration
may be more difficult, they may be less likely to tolerate oral fluids, and
assessment of mental status changes may be more difficult.
172
CASE 2:
MODERATE DKA
A six-year-old girl presents to your ED with her parents complaining
of abdominal pain with nausea and vomiting throughout the day. The
patient’s mother states the child looks more lethargic than normal, has
not been drinking, and is making very dark urine today.
On exam, she is alert and oriented with a GCS of 15, but she appears
drowsy. Vitals are: heart rate 135, respiratory rate 50, and blood pressure
89/50. Capillary refill is two seconds and the mucous membranes are dry.
Chest is clear and there is no indrawing. Abdominal exam is benign.
Investigations are remarkable for a pH of 7.1, a HCO3 of 7 mmol/l and a

potassium is 5.1 mmol/l.
Q: What will be your next step in the management of this six-

year-old lethargic child with suspected DKA?
A: This patient is clearly sicker than the previous case. However, she is
not in decompensated shock, as her systolic blood pressure is greater
than the minimal acceptable for her age (70 + [2 x age]). Her pH and HCO3
are consistent with moderate DKA. Remember that it took a few days to
develop these metabolic derangements in DKA, and there is no rush to
correct them immediately. In fact, aggressive fluid and insulin boluses
may increase the risk of cerebral edema. It is important to follow the DKA
algorithm provided by your hospital or the Canadian Diabetes Association
in consultation with your pediatrician or pediatric endocrinologist.
Pitfall:
One of the common pitfalls in the management of hemodynamically stable
pediatric DKA patients is employing aggressive fluid management with large
boluses of saline up front. This practice increases the risk of cerebral edema.
173
Q: How will you provide IV fluid rehydration for this patient?
A: The fluid of choice is normal saline. This patient is not in decompensated

shock and so there is no role for fluid boluses. The goal is to provide
maintenance fluid and replace her deficits over 48 hours. It is very common
to overestimate the degree of dehydration in DKA patients, partly because
their mucous membranes will appear dry due to their tachypnea. Our
experts recommend that IV fluids should be administered at no greater
than twice the maintenance rate.
Q: When will you administer insulin in this child, and at what

rate?
A: Insulin should be administered after one to two hours of intravenous

fluids. A case-control study found that early administration of insulin was
associated with increased risk of cerebral edema. This is the reason that
insulin administration is delayed in the current guidelines. Initial insulin
infusion should be between 0.05-0.1 unit/kg/hour in consultation with your
pediatrician or pediatric endocrinologist. There is no role for insulin boluses
in these patients, again due to an association with cerebral edema.
The metabolic derangements of DKA took one to two days to develop, and
so they should be corrected over one to two days, as well.
Key Reference:
In a U.K. case-control study of cerebral edema complicating diabetic

ketoacidosis in children, the researchers found that, after allowing for severity
of acidosis, insulin administration in the first hour and volume of fluid
administered over the first four hours were associated with an increased risk of
cerebral edema.
174
Q: How will you manage the potassium level of 5.1 mmol/l

in this child?
A: Remember that patients in DKA have a whole-body depletion

of potassium due to the osmotic diuresis associated with elevated
blood glucose levels. However, the potassium level in the blood will
be relatively higher due to the acidosis shifting potassium stores into
While serum
the blood. The administration of insulin will push potassium back
ketones can be
into cells, which may cause hypokalemia. This puts the patients at
used to monitor
risk of hypokalemia-induced dysrhythmias. In adult DKA patients,
treatment, most
administration of insulin is held until the potassium is known. If the
clinicians will
potassium is below 3.3 mmol/l, the insulin is not started until the
monitor the
potassium can be replaced.
anion gap as a
marker of ketosis
Pediatric patients are less prone to dysrhythmias. The guidelines do
and ensure that
not require one to know the potassium level prior to starting insulin.
it is decreasing
Remember that the insulin infusion should not be started until one
with treatment.
to two hours of IV fluid has been administered. As such, it is very
likely that you will have the potassium level back within the time
you will be starting insulin. If the initial potassium is found to be less
than 5.5 mmol/l and the patient is making urine, 40 mEq KCl should
be added to your IV normal saline infusion. ECGs are not routinely
indicated unless the patient is hypokalemic or hyperkalemic on the
initial blood work.
Q: Following these initial interventions, how are you going to monitor this
child to determine how to adjust further treatment?
A: The DKA algorithm provided by your consultant will inform further care, but the
principles of ongoing monitoring interventions in DKA are outlined below:
1. Check bedside glucose hourly

2. Check electrolytes and VBG every two hours initially
3. Add potassium to your normal saline infusion as 40 mmol KCl once serum potassium is
< 5.5 mmol/l and the patient is making urine
4. Add D10W or D5W to the infusion once glucose is 14.0–17.0 mmol/l
5. Target a blood glucose of 10.0–15.0 mmol/l with a dextrose infusion
175
CASE 3:
SEVERE DKA AND CEREBRAL EDEMA
A two-year-old girl presents to your ED with lethargy for the
past 24 hours. She has no infectious signs or symptoms and
there are no sick contacts. The excellent triage nurse carries
the child in her arms directly to your resuscitation room, as
she is really worried about her. She looks altered and is not
responding appropriately. She is very tachypneic.
Vital signs are: heart rate of 150, blood pressure 80/50,

respiratory rate 44, and oxygen saturation of 96%. The capillary
glucometer displays critically high readings. She is breathing rapidly and
deeply, capillary refill is three to four seconds, and extremities are cool.
There are no focal findings on gross neurologic exam. The blood gas
reveals a pH of 7.03 and a HCO3 of 3 mmol/l. Your heart rate goes up.
Q: Does this patient require an IV fluid bolus?
A: This patient is in severe DKA, as evidenced by her pH and bicarbonate

level. However, her blood pressure is greater than the minimal acceptable
blood pressure for her age, and therefore she is not in decompensated
shock. The acidosis in this patient can lead to mottling and delayed capillary
refill that may cause one to overestimate the degree of dehydration in
these patients. Judicious use of fluids with a maximal infusion rate of twice
the maintenance still applies to this patient as in the previous case. At
this point, an IV fluid bolus would not be warranted. If this patient does
develop decompensated shock (defined as hypotension adjusted for age)
then a normal saline bolus of 5–10 cc/kg can be administered with close
monitoring to reduce the risk of excess fluid administration. Given the
association of excess IV fluid administration with cerebral edema, it is
important to be judicious with fluid administration.
176
Q: What diagnosis would you consider given this

patient’s altered mental status? How will you
manage this?
Clinical Pearl:
A: This patient is presenting with altered mental status
If you have a in the presence of severe DKA. The possibility of cerebral
patient with DKA edema must be considered. In addition to the previously
with altered stated care plan, it would be prudent to:
mental status,
presume they have 1. Elevate the head of the bed to 30 degrees to help
cerebral edema. decrease raised ICP
Administration 2. Prepare mannitol and/or 3% hypertonic saline
of mannitol or 3. Call your regional referral centre, as this patient will
hypertonic saline require admission to a pediatric ICU
should be strongly
considered. Case continued: The patient is given a 400 ml bolus of
normal saline as well as an IV insulin bolus. The nurse
calls you back to the bedside because the child is now
stuporous and incontinent of urine. Her heart rate has
decreased from 150 to 90 beats per minute, and her
blood pressure has increased to 140/10 mmHg.
Q: What is the likely cause of this sudden

decrease in heart rate and increase in blood
pressure?
A: This child is likely suffering from cerebral edema with

a significantly raised intracranial pressure resulting in a
Cushing reflex.
177
Q: What are the risk factors for cerebral edema in DKA?
A: Cerebral edema is a rare but devastating complication of DKA. Risk factors for the
development of DKA can be divided into patient-related and treatment-related. These risk
factors are summarized in the table below. Note that these are only associations only,
derived mostly from retrospective studies. The pathogenesis of cerebral edema in DKA is
quite controversial. Theories attributing it to aggressive insulin and fluid administration
describe increased intracellular sodium, with the forcing of water into brain cells a
possible mechanism. Alternatively, cerebral hypoperfusion from dehydration and acidosis
in DKA, causing cytogenic edema, has been proposed. Certainly, patients in severe
DKA can present to the ED already with signs of cerebral edema, so it is unlikely it is a
phenomenon caused exclusively by overzealous insulin and IV fluid administration.
Risk Factors for Cerebral Edema in DKA
Q: What are your immediate steps in the management of this patient who is
now showing signs of cerebral edema with raised intracranial pressure (ICP)?
A: The patient’s mental status has declined and she now has signs of increased ICP,
as suggested by her hypertension and bradycardia, both part of the Cushing reflex of
increased ICP. The head of the bed should be elevated to 30 degrees. Administer mannitol
0.5–1 g/kg over 20 minutes and/or 3% hypertonic saline 5-10 cc/kg IV over 30 minutes.
Hypertonic saline has the theoretical benefit of preventing hyponatremia as well as
preventing hypovolemia caused by mannitol-induced osmotic diuresis. However, there is
no strong clinical evidence in the pediatric population to support one agent over the other.
178
A head CT can be considered to evaluate for increased ICP, but only after the patient
has stabilized. In fact, CT findings of cerebral edema usually lag behind clinical
symptoms, so management should proceed based on clinical signs of cerebral edema.
Head CT showing loss of sulci indicative of raised intracranial pressure
179
Q: Will you give this patient sodium

bicarbonate for her severe acidosis?
A: While sodium bicarbonate therapy has not been

demonstrated to show clinical benefit in adult DKA Clinical Pearl:
patients, guidelines suggest considering it in patients
with a pH < 7.0. This is not the case for pediatric Administration of
DKA patients. There is no evidence of benefit for this sodium bicarbonate
therapy in pediatric DKA patients and there is a weak in pediatric DKA
association with cerebral edema. Administration of should be limited
sodium bicarbonate should be limited to the pediatric to the patient who
patient who is in cardiovascular collapse. is in cardiovascular
collapse.
Q: If the patient becomes comatose and
requires intubation, what issues would you
need to consider?
A: Intubation of the severe DKA patient is a very risky

procedure and should ideally be done in consultation
with a pediatric intensivist. The tachypnea of DKA
patients serves to release large amounts of CO2 as a Pitfall:
respiratory compensation for the severe metabolic
Prior to intubation, it
acidosis. Prolonged apnea during intubation
is important to note
and hypoventilation post-intubation can cause
the patient’s pC02
accumulation of CO2 in the blood, rapidly worsening
as this should be
acidosis and possibly precipitating a cardiac arrest.
your target following
Prior to intubation, it is important to note the
intubation.
patient’s pC02 as this should be your target following
intubation.
180
Q: The patient in this case is clearly quite sick and will

be admitted to a pediatric ICU. What factors should guide
disposition of DKA patients?
A: General criteria for ICU admission in DKA are:
1. pH < 7.1 or HCO3 < 5 mmol/l

2. Age younger than two years old
3. Any concern for cerebral edema
As mentioned before, patients with mild DKA who are older than five years
of age and are tolerating oral fluids can be considered for discharge from
the ED if they are otherwise well, have clear follow-up instructions, and
have reliable caregivers.
FOAMed link: For a full pdf of the bottom line recommendations from TREKK,
click here.
Comments?

this podcast
181
KEY REFERENCES:
1. Edge JA, Jakes RW, Roy Y, et al. The UK case-control study of cerebral oedema complicating
diabetic ketoacidosis in children. Diabetologia. 2006; Sep;49(9):2002-9.
2. Koves IH, Neutze J, Donath S, et al. The accuracy of clinical assessment of dehydration during
diabetic ketoacidosis in childhood. Diabetes Care. 2004; Oct;27(10):2485-7.
3. Levin DL. Cerebral edema in diabetic ketoacidosis. Pediatr Crit Care Med. 2008; May;9(3):320-9.
4. Ma OJ, Rush MD, Godfrey MM, Gaddis G. Arterial blood gas results rarely influence emergency
physician management of patients with suspected diabetic ketoacidosis. Acad Emerg Med. 2003;
Aug;10(8):836-41.
5. Sheikh-ali M, Karon BS, Basu A, et al. Can serum beta-hydroxybutyrate be used to diagnose
diabetic ketoacidosis?. Diabetes Care. 2008; Apr;31(4):643-7.
6. TREKK. Bottom Line Recommendations: Diabetic Ketoacidosis. 2014. http://cme02.med.
umanitoba.ca/assets/trekk/assets/attachments/39/original/Bottom_Line_Summary_DKA.
pdf?1415132311.
7. Wherrett D, Huot C, Mitchell B, Pacaud D. Type 1 diabetes in children and adolescents. Can J
Diabetes. 2013; Apr;37:Suppl 1:S153-62.
8. Wolfsdorf JI, Allgrove J, Craig ME, et al. Diabetic ketoacidosis and hyperglycemic hyperosmolar
state. Pediatr Diabetes. 2014; Sep;15(20):154-79.
182
CHAPTER 12:
BRONCHIOLITIS
LISTEN TO THE PODCAST WITH DENNIS SCOLNIK AND SANJAY MEHTA HERE
LISTEN TO THE BONUS BRONCHIOLITIS PODCAST WITH AMY PLINT HERE
Objectives
1. Develop an approach to the clinical exam of a patient with respiratory distress
2. Learn how to distinguish between bronchiolitis, asthma and pneumonia clinically
3. Know which investigations are necessary for children with bronchiolitis
4. Develop an approach to the management of bronchiolitis with an understanding
of the evidence supporting various treatment modalities
5. Learn which children with bronchiolitis require admission
183
CASE 1:
DIFFICULTY BREATHING
A six-month-old girl is brought to the emergency department by her parents
because the child is having difficulty breathing. She’s had a cough and runny
nose for the past three days and gradually increasing shortness of breath since
the previous evening. This is her second ED visit.
On the first visit she was treated with ibuprofen and nebulized salbutamol,
and sent home. Her past history reveals that she was an uneventful delivery
with no NICU admission and no history of reactive airways. She is otherwise
healthy. Both her mother and father had asthma when they were children.
Q: As you are about to start you physical exam, you recall the Pediatric
Assessment Triangle and go through in your head all its components
to help guide your exam and to determine how “sick” this child is.
What are the important aspects of the Pediatric Assessment Triangle
that can help you out when faced with a six-month-old child with
respiratory distress in front of you?
A: Use the ABCs of the Pediatric Assessment Triangle:
Appearance: Work of Breathing:

•• Tone •• Respiratory rate
•• Interactiveness •• Abnormal breath sounds
•• Consolability •• Retractions
•• Look/gaze •• Tripod position
•• Speech/cry •• Nasal flaring
Circulation:
•• Pallor
•• Mottling
•• Cyanosis
184
Clinical Pearl:
It is also important to assess the hydration status of a child who presents

to the ED in respiratory distress. An increased respiratory rate with nasal
congestion can impair feeding ability and lead to dehydration. Ask about the
number of wet diapers, check the mucus membranes, look for sunken eyes,
and assess cap refill and skin turgour.
Case continued: The patient’s vitals are: heart rate 150, respiratory rate 55,
oxygen saturation 95% on room air, and a temperature 38.4°C. On exam, the
patient is alert and does not appear toxic, but is in moderate respiratory distress
with tracheal tugging and intercostal indrawing. Auscultation reveals bilateral
diffuse biphasic wheezes with no crackles. Mucous membranes are moist,
anterior fontanelle is flat, and capillary refill is one second. The rest of the exam is
unremarkable.
Q: This six-month-old child seems to be working pretty hard to breathe.

What is the upper limit of normal respiratory rate for a six-month old?
A:
Upper Limit of Normal Respiratory Rate:

•• Term neonate 50 breaths/minute
•• Six-month-old 40 breaths/minute
•• 12-month-old 30 breaths/minute
Q: You’re thinking that this child likely has reactive airways disease—
either an asthma-type illness, since both her parents were asthmatics,
or bronchiolitis, which you know is the most common lower respiratory
tract infection in those younger than two years of age and one of the
leading causes of hospital admission in those under six months of age.
Or could this be pneumonia?
185
You wonder, how does one tell the Q: This six-month-old girl’s
difference between asthma, pneumonia, parents are quite anxious,
and bronchiolitis clinically, at the bedside? and they want to know if you
are going to order a chest
A: Bronchiolitis may present in the “classic” X-ray. Is this necessary?
fashion with a first-time wheezing episode in the
first year of life between the months of November A: In our case, a chest X-ray is not
and April in northern climates. Bronchiolitis necessary. Chest X-ray findings
usually begins with a two- or three-day viral of bronchiolitis are often non-
prodrome of fever, cough, and runny nose, which specific.
progresses to tachypnea, wheeze, crackles, and
a variable degree of respiratory distress, usually They may show hyperinflation,
with a decreased oxygen saturation. It usually perihilar fullness (see below), and
lasts about 10 days, with the severity increasing areas of atelectasis that are often
over the first three to five days. misinterpreted as a consolidation
and lead to inappropriate
However, often it is not possible to distinguish antibiotic use.
bronchiolitis from asthma or pneumonia at first
contact because their presentations may overlap. However, one should consider a
chest X-ray when the diagnosis
Children with asthma usually presents with is unclear or pneumonia
recurrent wheezing in a child younger than two is suspected due to severe
years old with a personal and/or family history of respiratory distress, focal
atopy or asthma. Response to beta-agonists may lung findings on clinical exam
help to differentiate bronchiolitis from asthma, or unexpected response to
as typically patients with bronchiolitis do not treatment.
show any improvement following beta-agonist
administration, whereas asthma patients typically
do.
Children with bacterial pneumonia often appear

“toxic” and tend to have higher-grade fevers than
those found in bronchiolitis. They may have focal
chest findings and usually do not have wheeze.
186
Perihilar fullness seen on chest X-ray in a child with bronchiolitis
Key Reference:
The American Association of Pediatricians’ (AAP) Clinical Practice Guideline: The

Diagnosis, Management, and Prevention of Bronchiolitis states: “Clinicians should
diagnose bronchiolitis and assess disease severity on the basis of history and
physical examination. Clinicians should not routinely order laboratory and
radiologic studies for diagnosis.”
187
Q: The nurse asks you if you would like him to swab the nose of
this six-month-old child for respiratory syncytial virus (RSV).
While your reflex answer is ,“Sure, why not?” you’re actually not
sure if there is any value in RSV swabs for patients who present
to the emergency department with suspected bronchiolitis. Is
there any value in doing an RSV swab for this patient?
A: There is no need to do an RSV swab for this patient. Bronchiolitis is a

clinical diagnosis and a swab will not change the management. However,
there are certain populations for whom you may consider doing a swab,
such as those who were a premature delivery, recently discharged from
hospital, are immunocompromised, or are ventilated.
Q: The parents say their daughter’s nasal congestion has been

much worse over the past 24 hours, and that they read online
that they should be doing nasal suctioning. They ask, “What are
your thoughts about this?”
A: A trial of gentle nasal suctioning in the ED is reasonable. This is especially

true for younger children because they are obligate nose breathers. Nasal
suctioning may relieve some of the upper airway obstruction and reduce
the patient’s work of breathing. However, the evidence for nasal suctioning
is unclear, with one study showing that in-hospital suctioning actually
increased length of stay.
Q: The parents hear the word “wheezy” and remind you that they
both had asthma as a child. Should this child be treated with
inhaled bronchodilators?
A: Both the literature and recent guidelines report minimal evidence

of benefit for bronchodilators in bronchiolitis. Studies have shown
improvement in clinical scores but have not been shown to improve oxygen
saturation, admission rates, or length of stay. If a trial of salbutamol is
going to be attempted, the clinician should objectively assess the work of
breathing before and after its administration and continue therapy only if a
clinical benefit is noted.
188
Q: Is there a role for nebulized epinephrine

in children suspected of bronchiolitis in the
emergency department? Our experts recommend
considering a trial of
A: There is some evidence to suggest that nebulized salbutamol for patients
epinephrine may provide short-term benefit, but it may in whom there is a strong
ultimately delay the need for admission. family history of asthma,
atopy or in the patient who
Nebulized epinephrine may be considered in patients has had multiple wheezing
in whom you suspect admission will be the likely episodes. Ipratropium
disposition. If there is going to be a trial of nebulized should be reserved for
epinephrine, our experts suggest you monitor the asthmatic patients and not
patient objectively for benefit of treatment to guide used in bronchiolitis.
further management.
Q: Would this six-month-old child with

suspected bronchiolitis benefit from oral Key Reference:
steroids? What about the combination of oral
A Cochrane Review in
steroids and nebulized epinephrine?
2011 found that nebulized
epinephrine reduced
A: Corticosteroids alone are not recommended in
admission rates on day
bronchiolitis. Both a 2013 Cochrane Review and a
one; however, there was no
2014 systematic review in Annals of Emergency Medicine
difference in hospitalization
showed no benefit of oral steroids with respect to
rates at day seven when
length of stay and admission rates for children with
compared with placebo.
bronchiolitis.
Key Reference:
The evidence for the combination of oral steroids with nebulized epinephrine
is equivocal. A large randomized control trial by Plint et al. demonstrated
a trend toward decreased admission rates for children treated with a
combination of oral steroids and nebulized epinephrine. However, some
experts believe the clinical significance of this difference was very small, and
therefore do not recommend this treatment routinely.
189
Q: In between seeing patients, you stop to chat with one of

your colleagues. You tell him about the six-month-old with
difficulty breathing, and he asks if you tried hypertonic saline.
You had never heard of using hypertonic saline before and
wonder whether it is worth trying. You figure it’s probably
pretty harmless, and if it might benefit your patient, then great!
Is there a role for nebulized hypertonic saline in bronchiolitis
management?
A: Once again, the evidence is equivocal for the use of hypertonic saline
in the ED. There is evidence for its use in hospitalized patients, in whom
it has been shown to reduce length of stay and severity scores. However,
the benefits are short term and have not been shown to consistently
reduce rates of admissions or improve oxygenation. Our experts view
this treatment as a temporizing measure for a patient who is going to be
admitted and not as a rescue manoeuvre.
Q: Given the lack of good evidence for benefit for most treatment
modalities, what is your approach to the management of patients
with bronchiolitis?
A:
1. Correct hypovolemia
2. Treat hypoxemia if the oxygen saturation is less than 90%
3. Treat fever for comfort
4. Do serial assessments to determine the need for further interventions
5. Consider a trial of salbutamol if there is a history of atopy or a family
history of asthma or atopy
6. If admission is anticipated, consider a trial of epinephrine and/or
hypertonic saline
7. If showing signs of severe respiratory distress, high-flow oxygen is an
option (see Case 3)
190
Management of Bronchiolitis:
Adapted from The Canadian Paediatric Society Guidelines for Bronchiolitis, 2014
Recommended Evidence equivocal Not

treatments 1. Nebulized recommended
1. Oxygen epinephrine 1. Salbutamol
2. Hydration 2. Nasal suctioning 2. Steroids
3. Nebulized 3% saline 3. Antibiotics
4. Combined 4. Cool mist
epinephrine and therapies
dexamethasone
Q: After the child has received nasal suctioning, oxygen, and

fluids, you reassess this child who now appears to be well,
with no respiratory distress and normal vital signs except for
an oxygen saturation of 92%. Does this child with presumed
bronchiolitis require admission to hospital?
A: Key Reference:
One study of otherwise healthy infants between the ages of four weeks to
12 months, with mild to moderate bronchiolitis and true oxygen saturations
of 88% or higher, were randomized to pulse oximetry measurements with
true saturation values displayed or with altered saturation values displayed
that had been increased three percentage points above the true values.
191
The primary outcome was hospitalization within 72 hours, defined as

inpatient admission within this interval or active hospital care for greater
than six hours.
They found that those with an artificially elevated pulse oximetry reading
were less likely to be hospitalized within 72 hours or to receive active
hospital care for more than six hours than those with unaltered oximetry
readings. This suggests that oxygen saturation should not be the only
factor in the decision to admit, and its use may need to be re-evaluated.
CASE 2:
AN INFANT WITH FEVER & BRONCHIOLITIS
A seven-week-old female is brought to the emergency department by
her parents with a two-day history of fever, runny nose, and cough. She
is previously healthy with an uncomplicated delivery.
On exam, her vitals are: heart rate 140, respiratory rate 60, oxygen
saturation 97% on room air, and a temperature of 38.5°C. She is alert
and interactive. She has intercostal indrawing and bilateral expiratory
wheeze on auscultation. She appears well hydrated. The rest of the exam
is non-contributory.
Q: In this seven-week-old infant who is presenting with a

clinical picture consistent with bronchiolitis, you wonder
whether there might be a concurrent bacterial infection, which
would require a change in management. What is the risk of her
also having a serious bacterial infection?
A: Approximately 5% to 10% of infants with bronchiolitis will have a

concurrent serious bacterial infection, most commonly a urinary tract
infection.
192
Q: Knowing that 5% to 10% of infants with bronchiolitis will have

a concurrent serious bacterial infection, you wonder how to
decide which children with bronchiolitis require a workup for
a serious bacterial infection. Should you work up this seven-
week-old infant?
A: Strongly consider obtaining a urinalysis for all infants who present with
fever and bronchiolitis. All infants from birth to 28 days of age with a fever
require a full septic workup and should be started on empiric IV antibiotics,
regardless of any suspicion for bronchiolitis. All febrile infants who display
signs of septic shock or impending septic shock should also have a full
septic workup and be started on empiric IV antibiotics.
Q: When you go to reassess this infant, her mother tells you she
thinks her baby may have stopped breathing for a few seconds
in the ED. Is this seven-week-old female at risk for apnea with
her bronchiolitis? Can the risk be predicted?
A: Yes, she is at increased risk because she is younger than two months of
age. The overall incidence of apnea in children with bronchiolitis is 2.7%.
Risk factors for apnea with bronchiolitis include:
•• Age younger than 2 months

•• Small for gestational age (weight < 2.3 kg)
•• Previous episode of apnea
•• Oxygen saturation < 90%
193
CASE 3:
FEVER AT THREE MONTHS OF AGE
A three-month-old male is brought in to the emergency department by his
parents with a three-day history of runny nose and cough. He has felt warm
at home. Over the past 24 hours his parents have noticed that he is not
acting himself, has decreased feeding, and increased work of breathing. He
is previously healthy and was born at term with an uncomplicated delivery.
On exam, his vitals are: heart rate 160, respiratory rate 70, oxygen
saturation 89% on room air, and a temperature of 38.1°C. He is not very
interactive. He is working hard to breathe with tracheal tugging, nasal
flaring, and intercostal indrawing. On auscultation, you hear a bilateral
diffuse biphasic wheeze with no crackles. His mucus membranes are
dry and his capillary refill is three seconds. The rest of the exam is non-
contributory.
Q: For this child who is presenting with more severe respiratory

distress, what additional treatments will you consider in addition
the medications discussed in Case 1?
A: There is conflicting evidence for the use of CPAP and high-flow nasal
cannula for respiratory failure in bronchiolitis. However, our experts
recommend the use of warmed, humidified high-flow oxygen by facemask
for children with bronchiolitis who are in severe respiratory distress.
High-flow oxygen may not be tolerated by all patients, but in those who are
showing signs of fatigue and in whom you are considering intubation, it may
play a role. High-flow oxygen by facemask provides positive end expiratory
pressure (PEEP) and allows the delivery of a high concentration of oxygen.
While ketamine is an option in these patients, it is not recommended

by our experts unless it is going to be used in as an induction agent for
tracheal intubation. While it may have benefit in asthmatic patients due to
its broncho-dilatory properties, bronchoconstriction is not thought to play a
significant role in bronchiolitis, and thus ketamine is unlikely to be of benefit.
194
FOAMed link: For more on high-flow oxygen for bronchiolitis, check out this
PEM Currents podcast.
Q: After receiving nasal suctioning, nebulized epinephrine,

dexamethasone, and high-flow oxygen, this child who presented
in severe respiratory distress improves substantially. When you
go to reassess him, he looks great! You wonder whether this child
can go home with good discharge instructions. What are the
criteria for admission for a child with bronchiolitis according the
Canadian Paediatric Society 2014 guidelines?
A:
Admission criteria for bronchiolitis:
1. Signs of severe respiratory distress (i.e., indrawing, grunting, or

respiratory rate > 70)
2. Supplemental oxygen required to keep saturations above 90%
3. Dehydration or history of poor fluid intake
4. Cyanosis or history of apnea
5. Family unable to cope
6. Infant at high risk for severe disease (born at less than 35 weeks
gestation, younger than three months old, hemodynamically
significant cardiopulmonary disease, immunodeficiency)
Clinical Pearl:
Bronchiolitis symptoms peak around days three to five.

Comments?
If the patient presents on day two, you can expect the
patient may get worse before they get better. This should Click here to
be factored into your disposition decision. Also, 50% of leave a comment
patients who develop severe disease do so after their first or to listen to
ED visit, so clear discharge instructions are very important. this podcast.
195
KEY REFERENCES:
1. Ecochard-Dugelay E. Beliah M, Perreaux F, et al. Clinical predictors of radiographic abnormalities
among infants with bronchiolitis in a paediatric emergency department. BMC Pediatr. 2014;
Jun;14:143.
2. Fernandes RM, Bialy LM, Vandermeer B, et al. Glucocorticoids for acute viral bronchiolitis in
infants and young children. Cochrane Database Syst Rev. 2013; Issue 6.
3. Friedman JN, Rieder MJ, Walton JM, Canadian Paediatric Society, Acute Care Committee, Drug
Therapy and Hazardous Substances Committee. Bronchiolitis: Recommendations for diagnosis,
monitoring and management of children one to 24 months of age. Pediatr Child Health. 2014;
Nov;19(9):485-498.
4. Hartling L, Bialy LM, Vandermeer B et al. Epinephrine for Bronchiolitis (Review). Cochrane Database
Syst Rev. 2011; Issue 6.
5. Plint AC, Johsnon DW, Patel H, et al. Epinephrine and dexamethasone in children with
bronchiolitis. N Engl J Med. 2009; May;360(20):2079-2089.
6. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: The diagnosis,
management and prevention of bronchiolitis. Pediatrics. 2014; Nov;134(5):e1474-1502.
7. Ng C, Foran M, Koyfman A. Do glucocorticoids provide benefit to children with bronchiolitis? Ann
Emerg Med. 2014; Oct;64(4)389-91.
8. Schuh S, Freedman S, Coates A, et al. Effect of oximetry on hospitalization in bronchiolitis: a
randomized clinical trial. JAMA. 2014; Aug;312(7):712-8.
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CHAPTER 13: ASTHMA

LISTEN TO THE PODCAST WITH DENNIS SCOLNIK AND SANJAY MEHTA HERE
Objectives
1. Determine the severity of asthma to guide ED management
2. Distinguish asthma from common asthma mimics
3. Understand the evidence for various treatments for acute asthma exacerbations
4. Understand the dangers of endotracheal intubation in patients with severe asthma
5. Know the discharge and hospital admission criteria for pediatric asthma
197
CASE 1:
HISTORY OF ASTHMA
A 10-year-old boy with a history of asthma is triaged to the acute area of
your ED with a seven-day history of shortness of breath. Today, during
recess at school, he suddenly became much more short of breath and his
inhaler was empty from using it the day before. EMS brought the child
to your ED. On arrival he appears alert but tachypenic, with nasal flaring
and accessory muscle use. He’s able to speak in single-word phrases.
His respiratory rate is 40, heart rate is 140, oxygen saturation is 88% on
room air, and temperature is 37.4oC. His chest is silent.
Q: You are taking a quick history and you’re wondering about

how severe his asthma has been in the past. What historical
features would make you more worried that this child has severe
asthma and that he is at high risk for deterioration in the ED?
A:
•• Previous life-threatening exacerbations
•• Admissions to ICU
•• Intubation
•• Deterioration while on systemic steroids
•• Using more than two canisters of short-acting beta-agonist per month
•• Cardiopulmonary and psychiatric comorbidities
198
Pitfall:
A common pitfall is to assume that the lack of risk factors means that the
patient is low risk for deterioration. It is important to realize that a lack
of risk factors does not necessarily confer a lack of risk. In the absence of
the risk factors above, asthmatic patients may still have a severe disease
course and deteriorate in the ED.
Q: Although you think this is likely an asthma exacerbation,

what are some other possible diagnoses or mimics, and how do
you distinguish them from asthma?
A:
1. Bronchiolitis: Low-grade fever, wheeze tends to sound harsher and
less melodious; for more on bronchiolitis, jump to Chapter 12
2. Airway FB: Symptomless period followed by paroxysms of respiratory
distress, choking, recurrent or unresolving pneumonia, unilateral
wheeze, failure to improve with asthma therapies.
3. Tracheomalacia: Usually within first two months of life, strong
inspiratory component, no improvement with asthma meds—may
even cause worsening
4. GERD: Incidence among patients with asthma is as high as 48%;
heartburn, regurgitation, dysphagia
5. Pneumonia: Toxic appearing, respiratory distress, febrile, crackles
Q: Now that you’ve considered alternative conditions, you really

do believe this is an asthma exacerbation. You look up clinical
assessment tools for pediatric asthma to help guide you. These
are the Pediatric Respiratory Assessment Measure (PRAM) and
Pediatric Asthma Severity Score (PASS). How useful are these
scores in predicting severity?
199
Pediatric Respiratory Assessment Measure (PRAM)

Key Reference:
Birken et al. compared the

performance of various
assessment tools and concluded
the Clinical Assessment Score
and the Pediatric Respiratory
Assessment Measure (PRAM)
both reliably assess the severity
of an acute asthma exacerbation
and are sensitive to changes in
clinical status.
The Pediatric Asthma Severity

Score (PASS), based on three
clinical findings (wheezing,
prolonged expiration, and
work of breathing), is a reliable
and valid measure of asthma
severity in children and shows
both discriminative and
responsive properties.
Pediatric Asthma Severity Score (PASS)
200
Q: What are some other tools you can use

to help assess your patient’s disease and
severity? Caution:
A: Peak expiratory flow

should NOT be relied
upon solely as a
You can use peak expiratory flow to help exclude
measure of severity or
asthma mimics. An improvement by 15% or more
as a sole determinate
in peak expiratory flow after bronchodilator
for discharge.
therapy is very suggestive of reactive airways
disease or asthma in children (most reliable in
children 10 years and older).
You may also consider obtaining a blood gas. A

venous blood gas (VBG) is adequate. Metabolic
acidosis is an indicator of impending respiratory
arrest. A VBG, however, is rarely indicated Clinical Pearl:
unless the patient has no clinical improvement
despite maximal treatment. It is reserved for A normal partial
measuring the degree of respiratory acidosis pressure of CO2
and hypercapnea and may be most useful as a in a patient with
baseline after treatment in the ED for the patient extreme tachypnea
who will be admitted to the ICU. and retractions could
indicate impaired
A PaCO2 > 42 is indicative but not diagnostic of a ventilation and
severe exacerbation. impending respiratory
failure.
A PaCO2 > 50 is a risk factor for impending
respiratory failure.
201
Q: What about ordering imaging studies? Are there indications for a

chest X-ray in patients with wheezing?
A: You may want to consider obtaining a chest X-ray if the patient has:
•• Focal chest findings
•• Fever
•• Extreme distress
•• Subcutaneous emphysema
•• History of choking
No sets of predictors have been found to accurately identify children likely to

have abnormalities on chest radiograph. Chest X-rays are not recommended
for all wheezing in children. Upon reassessment after treatment, you may
find that the initial clinical focal findings have resolved, obviating the need
for a chest X-ray. This approach is cost0effective, limits radiation, and limits
unnecessary antibiotic use.
Q: You have ordered your peak expiratory flow and used your
clinical score. You are now even more confident that this is asthma
and, given his condition, you want to start treatment right away.
You are going to start with beta-agonist therapy. How will you
deliver this treatment?
A: Compared with nebulized treatments, a metered-dose inhaler (MDI) with a

spacer use has been shown to be equally effective for children of all ages with
a wide range of illness severity and by multiple outcome measures. Among
children one to four years old, using an MDI with a spacer was associated with
a greater reduction in wheezing and a lower hospitalization rate in one study.
Furthermore, a recent cost analysis determined that the use of MDIs to treat
children with mild to moderate asthma exacerbations in the ED could yield
significant cost savings compared with nebulized treatments. MDIs with a
spacer should not be used in patients with impending respiratory failure, and
it can be difficult to coordinate breathing with administration of the inhaler for
patients younger than one year old.
202
With respect to nebulized treatments, there is no need to coordinate the treatment

with breathing, and bronchodilators can be given concurrently with anticholinergics and
humidified oxygen. The downsides to using nebulized treatments are that only about 10% of
the drug reaches the small airways and they may increase the spread of airborne infections.
IV beta-agonists have not been shown to be superior to inhaled beta-agonists. IV beta-

agonists should be considered in those who are unable to tolerate nebulized or MDI
treatments.
Salbutamol Dosing:
•• For patients who weigh less than 15 kg, use Salbutamol MDI four puffs
or 2.5 mg nebulized + 3 ml NS.
•• For patients who weight more than 15 kg, use Salbutamol MDI eight
puffs or 5 mg nebulized + 3 ml NS.
Q: Will you use the nebulized treatments intermittently (every 15 minutes) or

continuously?
A: A Cochrane systematic review found that those treated with continuously

nebulized bronchodilators had lower rates of hospitalization, greater improvements
in pulmonary function test results, and similar rates of adverse events compared
with those treated intermittently. Continuous treatment allows greater compliance with the
goal of delivering the equivalent of three intermittent bronchodilator treatments in the first
hour of care. In addition, this method will result in less respiratory therapy time and costs;
it has been shown to be safe, and it may benefit the sickest patients the most. On the other
hand, young children may not tolerate a face mask for prolonged periods.
Caution:
In children receiving multiple beta-agonist treatments, watch for hypokalemia,

especially if the patient has diarrhea or is on diuretic medications.
203
Q: You have started your beta-agonist therapy and

are waiting optimistically for an improvement in
your patient. What are some other treatments you
can give to your pediatric patient in the meantime?
Clinical Pearl:
A: Ipratropium-bromide! Beta-agonists with
ipratropium bromide are more effective than Ipratropium bromide
beta-agonists alone. In a large, double-blind should be given
randomized controlled trial, three doses of ipratropium concurrently with
bromide administered concurrently with the first three a beta-agonist.
beta-agonist treatments were shown to be superior to just Ipratropium bromide
one dose of ipratropium bromide. In a systematic review MDI four puffs
and meta-analysis comparing the use of beta-agonists (80 mcg) or 250 mcg
plus anticholinergics with beta-agonists alone among nebulized.
children older than 18 months combination therapy was
associated with significantly lower hospitalization rates
and improvements in asthma scores and pulmonary
function test results. These investigators concluded that
multiple doses of ipatropium bromide added to beta-
agonists should be standard treatment for children with Steroids:
moderate to severe asthma exacerbations. However, there
are no clinical trials supporting ipratropium use beyond Dexamethasone
the first hour in children. suspension 0.6 mg/
kg (max. 20 mg) OR
Q: What added benefit do steroids such as prednisone suspension
prednisone or dexamethasone have over beta- 1mg/kg (max. 60 mg).
agonists and ipratropium bromide?
Dexamethasone tastes
better and may be given
A: Steroids should be administered as early in the ED visit
in smaller volumes.
as feasible. Significant clinical benefits begin two hours
Studies show 0.6 mg/
after administration and are most pronounced among
kg for two days is just
the sickest children. A Cochrane Review demonstrated
as good as prednisone
that steroid use decreased the need for hospitalization,
for five days, and
decreased risk of relapse after initial treatment and
compliance may
may facilitate an earlier discharge from the hospital.
improve as a result.
Oral administration of steroids is just as effective as IV
administration.
204
Case continued: The 10-year-old boy has improved significantly and

has a good oxygen saturation, has no wheezing on auscultation, and
feels better, with an acceptable peak expiratory flow. You are ready to
discharge the patient.
Q: What discharge instructions will you give the parents?
A: Ensure the patient has an MDI spacer! If not, prescribe him one.
Every child should have the following discharge instructions:

•• Complete a two- to five-day course of oral steroids, depending on the
severity of the illness at presentation
•• Continue to use a short-acting beta-agonist, such as salbutamol (200
mcg [0.3 puffs/kg to a maximum of two puffs] every four hours) until
exacerbations resolve and then as needed, with directions to see a
health care professional if therapy is needed more often than every
four hours
•• Prepare a written asthma action plan
•• Review techniques for using inhaled asthma medications, as well as for
cleaning/maintaining the inhaler device
•• Encourage follow-up with the patient’s primary-care physician or a local
asthma clinic to review asthma control, environmental history, and
symptom recognition
While there is no evidence that the use of inhaled steroids in the ED

is beneficial, there is evidence that they decrease relapse rates in the
outpatient setting.
Let’s back up and pretend you have a similar scenario but with a patient
who clinically worsens despite continuous nebulized beta-agonist and
ipatropium bromide plus oral dexamethasone 0.6 mg/kg. His oxygen
saturation is now 86% and he is showing signs of fatigue. His GCS is 14,
and the nurse asks what you want to do next.
205
Q: What other treatments should you consider?
A: There is accumulating evidence that magnesium sulfate may benefit

children with severe asthma. Meta-analyses have shown that the use
of magnesium sulphate resulted in improved outcomes for both adults
and children, improving respiratory function and decreasing hospital
admissions. IV magnesium sulphate may be considered in cases of
moderate and severe asthma with incomplete response to conventional
therapy during the first one to two hours. The most common adverse
effect is hypotension; this may be avoided by infusion of the dose over 20
minutes. Both IV and inhaled magnesium sulphate are effective.
If a patient has responded poorly to a beta-agonist/ipratropium/systemic

corticosteroid/magnesium sulphate, then IV terbutaline can be considered
and may reduce the need for assisted ventilation.
Q: You have now tried everything you could think of for asthma,
except epinephrine. In what situations is epinephrine indicated?
A: Epinephrine is recommended for patients who are minimally responsive

or responding poorly to beta-agonists/ipratropium/systemic corticosteroid/
magnesium sulfate therapies, or who are unable to tolerate nebulized
treatments, that parenteral epinephrine be considered. Initially, IM
epinephrine can be given (0.01 mg/kg, max of 0.3 mg dose).
Q: One of the medical students mentions hearing about

something called heliox. What is heliox, and is there any role for
it in this context?
A: Heliox is a mixture of helium and oxygen. In conditions where there is

increased airway resistance (asthma, croup, upper airway masses, etc.)
there is turbulent airflow, which increases the work of breathing. Heliox can
reduce airway resistance by increasing laminar airflow, and decrease the
work of breathing.
206
Currently, systematic reviews and guidelines state that heliox should not be
used routinely in patients with acute asthma in the ED.
Using a helium-oxygen gas mixture is generally reserved for children in the

ICU setting with severe asthma exacerbation who have failed to improve
despite maximized therapy.
Caution:
Consider heliox in a patient with Heliox should not be given to

increased work of breathing in whom patients who require high oxygen
there has been no improvement with concentrations, as the ratio of
first- and second-line therapies. A helium to oxygen in heliox is
trial of heliox may help patients who 70:30 or 80:20, which does not
have conditions in which securing an deliver high enough oxygen
advanced airway may be challenging concentrations for patients who
(e.g., croup, asthma). are severely hypoxic.
Q: You have heard that if you need to intubate, ketamine is a

good choice as the induction agent. But you wonder: Is ketamine
useful in preventing the need for intubation in the worsening
asthmatic?
A: Current literature on this topic is mixed.
A limited case series has reported the effectiveness of a bolus (2 mg/kg)

followed by a continuous infusion (2–3 mg/kg/h) of ketamine in children
with severe asthma who were approaching respiratory failure. In this study,
the use of ketamine resulted in prompt improvement and avoided the need
for endotracheal intubation. This is an appealing use of ketamine, because
it may allow one to avoid the hazards of endotracheal intubation and
mechanical ventilation in the patient with asthma.
207
A randomized controlled trial showed no improvement in pulmonary index scores with

the administration of ketamine to patients with moderate to severe asthma. Patients
were randomized to 0.2 mg/kg ketamine bolus followed by 0.5 mg/kg/h for two hours
versus placebo. Pulmonary index scores were measured throughout the two hours and no
difference was found.
In a 2001 prospective, observational, single-arm pilot study in two pediatric EDs over three
months, the effect of IV ketamine added to standard therapy in status asthmaticus was
evaluated. Initiation of ketamine in patients with severe asthma was associated with clinical
improvement. Side effects were easily managed with treatment or discontinuation of
ketamine.
The take-home message is that more convincing evidence is required before ketamine can
be recommended for routine treatment of severe pediatric asthma to avoid intubation.
Ketamine, however, is safe at dissociative dosages, and is a reasonable option when all
others measures have failed.
Case continued: This 10-year-old boy who is now suffering from worsening status
asthmaticus is given IV magnesium and IM epinephrine in addition to continuous
salbutamol, and he continues to tire. His GCS has dropped to 13 and his VBG shows an
elevated CO2.
Q: What are your next steps in managing this patient?
A: Positive-pressure ventilation should be considered, and you should prepare for intubation.
Caution:
Up to 26% of children intubated due to asthma have such complications

as pneumothorax, impaired venous return, and cardiovascular collapse
because of increased intrathoracic pressure. Mechanical ventilation during
an asthma exacerbation is associated with an increased risk of death and
should be considered as a last resort and in conjunction with the support of
a pediatric ICU specialist.
208
The decision to intubate should be based on clinical judgment as

opposed to any single vital sign or blood gas result. Some variables to
consider for intubation are worsening hypercapnea, patient exhaustion,
and changes in mental status.
Q: What is your ultimate disposition for this 10-year-old

asthmatic? What are your criteria for admission in general?
A:
Criteria for Admission in Pediatric Asthma
Admission should be considered if any one of the following apply:

•• An ongoing need for supplemental oxygen
•• Persistently increased work of breathing
•• Beta-agonists are needed more often than q4 h after four to eight
hours of conventional treatment
•• The patient deteriorates while on systemic steroids
Other criteria may also be taken into consideration (e.g., distance from
home, comorbid conditions such as anaphylaxis).
ICU admission or referral to a tertiary-care centre should be considered

if the patient requires continuous nebulized salbutamol and fails to
improve on this therapy.
209
Q: Let’s say this 10-year-old asthmatic improved in the ED. What

are your discharge criteria for pediatric asthma?
A:
Discharge Criteria in
Pediatric Asthma
Discharge criteria from the ED include:

•• Needing beta-agonists less often than Comments?
q4 h after four to eight hours of Click here to
conventional treatment leave a comment
•• A reading of SpO2 94% on room air or to listen to
•• Minimal or no signs of respiratory distress this podcast.
•• Improved air entry
KEY REFERENCES:
1. Belessis Y, Dixon S, Thomsen A, et al. Risk factors for an intensive care unit admission in children
with asthma. Pediatr Pulmonol. 2004; Mar;37(3):201-9.
2. Gorelick MH, Stevens MW, Schultz T, Scribano PV. Difficulty in obtaining peak expiratory flow
measurements in children with acute asthma. Pediatr Emerg Care. 2004; Jan;20(1):22-6.
3. Parkin PC, Macarthur C, Saunders NR, Diamond SA, Winders PM. Development of a clinical
asthma score for use in hospitalized children between 1 and 5 years of age. J Clin Epidemiol. 1996;
Aug;49(8):821-5.
4. Chalut DS, Ducharme FM, Davis GM. The Preschool Respiratory Assessment Measure (PRAM): A
responsive index of acute asthma severity. J Pediatr. 2000; Dec;137(6):762-8.
5. Gorelick MH, Stevens MW, Schultz TR, Scribano PV. Performance of a novel clinical score, the
Pediatric Asthma Severity Score (PASS), in the evaluation of acute asthma. Acad Emerg Med. 2004;
Jan;11(1):10-18.
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6. Birken CS, Parkin PC, Macarthur C. Asthma severity scores for preschoolers displayed weaknesses
in reliability, validity, and responsiveness. J Clin Epidemiol. 2004; Nov;57(11):1177-81.
7. Ortiz-Alvarez O, Mikrogianakis A, Canadian Paediatric Society Acute Care Committee.
Managing the pediatric patient with an acute asthma exacerbation. Paediatr Child Health. 2012;
May;17(5):251-62.
8. Gershel JC, Goldman HS, Stein RE, Shelov SP, Ziprkowski M. The usefulness of chest radiographs
in first asthma attacks. N Engl J Med. 1983; Aug;309(6):336-9.
9. Castro-Rodriguez JA, Rodrigo GJ. Beta-agonists through metered-dose inhaler with valved holding
chamber versus nebulizer for acute exacerbation of wheezing or asthma in children under 5
years of age: A systematic review with meta-analysis. J Pediatr. 2004; Aug;145(2):172-7.
10. Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for beta-agonist
treatment of acute asthma. Cochrane Database Syst Rev. 2013; Issue 9.
11. Camargo CA, Spooner CH, Rowe BH. Continuous versus intermittent beta-agonists in the
treatment of acute asthma. Cochrane Database Syst Rev. 2003; Issue 4.
12. Rodrigo GJ, Castro-Rodriguez JA: Anticholinergics in the treatment of children and adults with
acute asthma: A systematic review with meta-analysis. Thorax. 2005; Sep;60(9):740-6.
13. Doymaz S, Schneider J, Sagy M. Early administration of terbutaline in severe pediatric
asthma may reduce incidence of acute respiratory failure. Ann Allergy Asthma Immunol. 2014;
Mar;112(3):207-10.
14. Rowe BH, Bretzlaff JA, Bourdon C, Bota GW, Camargo CA Jr. Intravenous magnesium sulfate
treatment for acute asthma in the emergency department: A systematic review of the literature.
Ann Emerg Med. 2000; Sep;36(3):181-90.
15. Mohammed S, Goodacre S. Intravenous and nebulised magnesium sulphate for acute asthma:
Systematic review and meta-analysis. Emerg Med J. 2007; Dec;24(12):823-30.
16. Cheuk DK, Chau TC, Lee SL. A meta-analysis on intravenous magnesium sulphate for treating
acute asthma. Arch Dis Child. 2005; Jan;90(1):74-7.
17. Denmark TK, Crane HA, Brown L. Ketamine to avoid mechanical ventilation in severe pediatric
asthma. J Emerg Med. 2006; Feb;30(2):163-6.
18. Allen JY, Macia CG. The efficacy of ketamine in pediatric emergency department patients who
present with acute severe asthma. Ann Emerg Med. 2005; Jul;46(1):43-50.
19. Petrillo TM, Forteberry JD, Linzer JF, Simon HK. Emergency department use of ketamine in
pediatric status asthmaticus. J Asthma. 2001; Dec;38(8):657-64.
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CHAPTER 14:
LUNG POCUS
LISTEN TO THE PODCAST WITH ALYSSA ABO HERE
Objectives
1. Understand the advantages of lung Point of Care Ultrasound (POCUS)
2. Understand the steps to perform lung POCUS to diagnose pneumonia
3. Understand the common pearls and pitfalls of lung POCUS
212
Q: I have treated pneumonia many-a-time without using the

complicated ultrasound machine. Why should I learn to do this?
A: Many children present to the emergency department with respiratory illnesses. Although
only a small number of these patients have pneumonia, a large number of these patients
receive chest X-rays. POCUS may be used not only to limit the number of chest X-rays
performed on patients, but also because it is more accurate than chest X-ray in diagnosing
pneumonia.
CASE 1:
THE CASE OF THE NON-RADIATING WAR ON
PNEUMONIA
A three-year-old boy presents to the emergency department with fever, cough, and
tachypnea. You order a chest X-ray and it shows the appearance of a complete whiteout
of the right hemithorax. You have a discussion with your emergency team, mostly
about placing a chest tube and obtaining a CT for this child. Someone mentions that you
should consider doing a bedside ultrasound of the lungs. POCUS is performed, and the
right lung shows a large pneumonia taking up the entire lung field with no fluid.
213
Q: With these findings and the clinical picture

favouring pneumonia, do you need a thoracic CT?
A: Since the clinical scenario and the ultrasound findings Use of lung POCUS
are in favour of pneumonia, you may not need to go on to has the potential to
further CT investigations. Other advantages of using POCUS decrease the number
for suspected pneumonia include: of chest X-rays
1. Differentiating pneumonia from a viral URTI or performed in pediatric
empyema patients in the future
2. Potentially diagnosing early bacterial pneumonia and can show the
before there is evidence of pneumonia on a chest X-ray lungs in more detail
3. Reliably diagnosing retro-cardiac infiltrates that are for some illnesses.
difficult to visualize on chest X-ray
Q: But what if you’re wrong? Perhaps a formal CT and a radiology opinion

may be better. Can clinicians diagnose pneumonia accurately with POCUS?
A:
Key Reference: Clinical Pearl:
Prospective evaluation of POCUS for the When performing an IVC,

diagnosis of pneumonia in children and FAST, or para-sternal
young adults long view of the heart,
•• 200 patients with a pneumonia portions of the lung may
prevalence of 18% be seen in these views.
•• POCUS for pneumonia: Sensitivity = Pay attention to these
86%; Specificity = 89% lung views. You may
•• Positive LR = 7.8; negative LR = 0.2 for pick up pathology that
diagnosing pneumonia you weren’t expecting
•• Study author’s conclusion: Clinicians to find that explains
are able to diagnose pneumonia the patient’s acute
in children and young adults using presentation.
POCUS with high specificity.
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Q: That makes you feel better. So, you see lots of different “lines”
when you look at the lungs. What are the common lines on lung
POCUS, and what do they all indicate?
A: There are many different “lines” present on POCUS. The most common
ones are A-lines, B-lines, and comet tails.
1. A-lines: These are artifact lines horizontal to the pleural line that
represent normal lungs
2. B-lines: These are hyperechoic lines that extend vertically from the
pleural line to the far field of the POCUS screen; they do not taper, they
move with respiration, they are pathologic, and they abolish A-lines; they
represent an interstitial process
3. Comet tails: These are hyperechoic artifacts that extend vertically from
the pleural line and taper in the far field and move with respiration;
these are seen in normal lungs, but may be absent in normal lungs
215
Q: You think you are convinced and are ready to start using POCUS for
pneumonia. What are the steps for lung POCUS?
A: Step 1: Find the landmarks
What is the ideal probe to use to look for pneumonia? Which orientation should
be used?
The pneumonia scan starts by placing a high-frequency probe in the longitudinal
plane on the child’s chest. This will help identify landmarks and the pleura. Depending
on the child’s body size, the low-frequency probe will be needed to look deeper into
the chest cavity to identify any evidence of pneumonia. Rotating the probe into the
transverse plane to look between the ribs and sweep can also be used.
What are the landmarks of pneumonia POCUS?

Identify two rib shadows (hypoechoic shadows streaking down the screen). The
hyperechoic, horizontal line approximately 1 cm below the rib is the pleural line.
Lines horizontal to the pleural line are A-lines.
216
Step 2: Scan each area for signs of consolidation

Clinical Pearl:
Now that you've identified the landmarks and
determined the best probe to use for pneumonia Regardless of which
POCUS, you need to ensure the entire lung field is approach is used, ensure
visualized. How do you do this? that a combination of
slides and sweeps are
There are many different approaches to ensure the entire employed to see the
lung field is visualized: entire lung field. It may
1. Thirty-two region approach: Divides the lung into require both transverse
32 regions and scans each separately and longitudinal
2. Diagonal approach: Starts at the superior portion of orientations (quite
the chest toward the sternum and moves diagonally possibly even an oblique
toward the flank view with the probe) to
3. Anterior, axillary, posterior approach: Divides the see the entire lung field.
lung into these three regions and looks superiorly
and inferiorly in these areas
Q: If you are looking for signs of consolidation, what do you need to watch for?
A: The distinctive features of consolidation on lung POCUS include:

1. Hepatization: The lung looks like liver tissue
2. Shred sign: Pleural edges look uneven and have irregular borders
3. Tissue sign: Looks like tissue instead of normal lung appearance
217
Clinical Pearl:
Retro-cardiac pneumonia can be diagnosed by performing a parasternal long view

of the heart and looking in the far field. In the setting of retro-cardiac pneumonia
there will be loss of mirror artifact, presence of B-lines, and other signs of
consolidation. Retro-cardiac pneumonia is often missed, even on chest X-ray.
218
Q: You think you are seeing consolidation, but you

wonder if it could just be atelectasis. How do you Pitfall:
differentiate between consolidation and atelectasis on
POCUS? Missing any
part of the lung
A: It is very difficult to determine the difference between fields with the
atelectasis and consolidation on POCUS. A characteristic to help ultrasound
distinguish between the two is air bronchograms (air in the probe may miss
bronchus much like it is seen on a chest X-ray). Although both important lung
atelectasis and consolidation can display air bronchograms, if air pathology.
bronchograms are dynamic during the respiratory cycle it should
prompt a higher suspicion for consolidation. However, clinical
correlation is required to help distinguish between the two.
Clinical Pearl:
When scanning the

lungs on the FAST exam,
seeing the spine in
the far field cephalad
to the diaphragm can
indicate the presence
of lung pathology (e.g.,
hemothorax, pleural
effusion, parapneumonic
effusion).
219
Q: When you are scanning, you may notice a bright white line
above the diaphragm, consistent with the spine. Why is the
spine seen so clearly in the setting of a hemothorax or pleural
effusion?
A: The lung is normally filled with air, which causes scatter of the
ultrasound beam. Thus, no far-field structures are seen through the
lung, as it makes for a poor acoustic window for the ultrasound beam.
However, when fluid is present in the lung from a hemothorax or pleural
effusion, it provides an excellent acoustic window, which allows beams to
pass through and identify far-field structures such as the spine. (Analogy:
Pregnant women need to fill their bladder before an obstetric ultrasound to
see the fetus through the bladder. If the bladder is not filled, it is difficult to
visualize the fetus.)
Video: Click here to watch a video of lung POCUS by Dr. Mike Stone.
Comments?

this podcast.
KEY REFERENCES:
1. Cortellaro F, Colombo S, Coen D, Duca PG. Lung Ultrasound is an Accurate Diagnostic Tool for the
Diagnosis of Pneumonia in the Emergency Department. Emerg Med J. 2012; Jan;29(1):19-23.
2. Shah VP, Tunik MG, Tsung JW. Prospective evaluation of POCUS for the diagnosis of pneumonia in
children and young adults. JAMA Pediatrics, 2013; Feb;167(2):119-25.
3. Lichtenstein D, Meziere G, Seitz J. The dynamic air bronchogram: A lung ultrasound sign of
alveolar consolidation ruling out atelectasis. Chest. 2009; Jun;135(6):1421-5.
220
CHAPTER 15:
PEDIATRIC CROUP
SPECIAL THANKS TO DENNIS SCOLNIK AND SANJAY MEHTA
Objectives
1. Review the differential diagnosis of stridor in children
2. Understand the value of imaging in children with stridor
3. List the evidence-based medications for croup
4. Review the criteria for admission for children with croup
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CASE 1:
A BARKING COUGH
A four-year-old boy is brought in to the ED by his mother on an early
winter evening. She is concerned about his strange sounding cough,
hoarse voice, and noisy breathing that she noticed while her son was
sleeping that evening. For the past few days he has had a mild cough and
runny nose. On exam he has a heart rate of 130, respiratory rate of 40,
blood pressure 90/60, an oxygen saturation of 99%, and temperature of
37.9oC. As you enter the patient’s room, you can hear a croupy cough and
stridorous respirations from across the room.
Q: As you start to examine this patient, what are you thinking

about in terms of a differential diagnosis?
A: The differential diagnosis of stridor in a child includes croup, bacterial

tracheitis, epiglottitis, foreign body, retropharyngeal abscess, and
anaphylaxis.
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Other less common diagnoses to be considered are:

•• Upper airway injury
Clinical Pearl:
•• Congenital upper airway anomalies
•• Acute angioneurotic edema In children younger
•• Neck mass than six months of age,
•• Laryngeal diphtheria check for cutaneous
•• Measles hemangiomas as a clue
that there may be a
Features that are not consistent with croup: subglottic hemangioma
•• Toxic-looking child causing stridor.
•• Drooling
•• Posturing to protect airway
•• Sore throat
Q: Common things being common, you think this might be

croup. What is croup?
A: Croup is a common upper airway infection caused mostly by

parainfluenza, but also by RSV, rhinovirus among others. It is seen in
children three months to six years of age with a peak incidence at two years
of age. It is typically seen in the fall and early winter and preceded by a
viral prodrome. The symptoms become more prominent at night with peak
symptoms around the second night of the illness.
Q: This boy is not very happy and keeps throwing the oxygen
saturation probe off of his finger. As you’re encouraging him to
keep it on, you wonder about the utility of an oxygen saturation
in a child with croup. How can the oxygen saturation of a child
with croup be misleading?
A: Oxygen saturation may be normal in a child with severe croup, or,

conversely, substantially lowered in a child with mild to moderate croup.
This variability presumably relates to ventilation–perfusion mismatching
caused by lower-airway disease.
223
Q: You finish assessing your patient and you are wondering

about ordering an X-ray. Under what conditions should a soft
tissue X-ray of the neck be obtained for presumed croup?
A: Croup is a clinical diagnosis and laboratory and imaging are not required
to make the diagnosis.
Performing an X-ray of the soft tissues of the neck is generally not

necessary or advisable in presumed croup, as information that would alter
the management of croup is rarely derived from an X-ray.
Imaging is typically reserved for children with findings suggestive of another

diagnosis, such as epiglottitis, retropharyngeal abscess, or aspirated foreign
body. Direct visualization via nasotracheal fibre-optic scope is generally
preferred over imaging.
Subglottic narrowing, radio-opaque foreign bodies, and supraglottic

swelling may be apparent on a technically good radiograph of the airway,
but the risk of the procedure generally outweighs any benefits, as the
neck extension required for the procedure may lead to sudden severe
obstruction. Managing a life-threatening upper airway obstruction in the
radiology department is not without challenges and risks!
Q: What treatments would you order for this four-year-old boy

with presumed croup?
A: Dexamethasone 0.6 mg/kg (max 20 mg) should be given to all patients

with croup in the ED. This is the preferred steroid due to its long half-life.
The literature shows an improvement in croup scores at six and 12 hours
after the first dose (but no difference at 24 hours) and a reduction in the
need for nebulized epinephrine treatment, as well as a reduction in the
need for hospital admission, length of stay, and return visits to the ED.
The literature shows, however, that there is no difference in the need for
intubation with dexamethasone when compared with placebo.
224
If the patient is unable to tolerate oral medications, use nebulized

budesonide 2 mg (4 ml of 0.5 mg/ml solution) delivered along with
nebulized epinephrine (if necessary). Alternatively, dexamethasone IM or
methylprednisolone IV may also be given.
Q: What are the indications for treating croup with nebulized

epinephrine?
A: Nebulized epinephrine is indicated for stridor at rest or marked

suprasternal retractions. It works through the vasoconstrictive alpha
effects to decrease airway mucosal edema. The onset of action is
10 minutes and the effects can last up to one hour. The literature
demonstrates that croup scores are improved at 30 minutes after first
dose, but at two hours and six hours there is no difference in croup
scores compared with placebo. The use of nebulized epinephrine has
been shown to reduce the rate of intubation, admission to hospital, and
admission to ICU for moderate to severe croup.
Racemic and regular epinephrine have equivalent efficacy and safety in

the management of croup. Racemic epinephrine was previously thought
to have fewer complications, but there are no data to support this. The
dosing of nebulized epinephrine is 0.5 ml/kg of 1:1000 epinephrine (max.
5 ml). This can be repeated once in 20 minutes in cases of severe croup.
225
Q: You begin to form your disposition plan for this four-year-old

boy. How long do children with croup need to be monitored in
the ED, and what are the criteria for sending them home?
A: Children who are treated with epinephrine they should be observed for
a minimum of three hours before being discharged from medical care.
Criteria for Safe Criteria for Hospital

Discharge Home Admission
Absence of inspiratory stridor Persistence of stridor at rest

at rest and respiratory distress and respiratory distress for four
(suprasternal, intercostal and hours or more after treatment
chest wall indrawing). with dexamethasone (or
another corticosteroid) and
repeated doses of nebulized
epinephrine.
Criteria for transfer to Children’s Intensive Care Unit
Persistent severe croup (stridor, often biphasic, severe chest wall

indrawing, and agitation) despite treatment with two doses of
nebulized epinephrine and oral dexamethasone within the first
two hours of assessment and treatment.
226
Clinical Pearl:
Always inform the family the child’s cough can last up to several weeks
and the stridor may recur during episodes of agitation/excitement.
Q: After you give the parents your discharge

instructions, they ask you about ways they can
help their child recover from croup at home. Is
there any evidence for effectiveness of humidified
air, mist therapy, or antitussives in the treatment
of croup?
A: There is no evidence for antitussives. They have no

proven effect on the course or severity of croup and may
increase sedation, thus interfering with assessment.
Codeine, in particular, should never be used in children or

breastfeeding mothers, as there have been several case
reports of death following codeine ingestion at therapeutic
doses.
There is no added benefit for treatment with humidified

air. It was previously widely used and is still commonly
recommended as a home treatment. Three studies in
hospital emergency settings provided data on 135 children
with moderately severe croup symptoms. No outcome For Dr. Anthony Crocco’s rant on
measures were significantly different between groups. codeine use in children, click here
Further research is needed in primary-care settings and to listen to his Best Case Ever.
using more sensitive measures of benefit. Mist therapy
is not effective in improving clinical symptoms in children
presenting to the ED with moderate croup.
227
Another case: A few shifts later, you have another four-year-old child with
a croupy cough and stridor. The child receives oral dexamethasone and
nebulized epinephrine and three hours later continues to be stridorous with
worsening retractions.
Q: How would you manage this child differently compared with the
previous case?
A: You may consider using heliox. However, heliox has not been shown to reduce
the need for intubation in severe croup.
In a child whose croup is progressing despite treatment in the ED, you should
prepare for intubation. Approximately 3 in 1,000 cases of croup require
intubation, with a mortality rate of < 0.5% in intubated patients.
Clinical Pearl: Pitfall:
When considering intubation in

Kids should never be
patients with croup, one must
discharged from the ED
anticipate a challenging airway
with stridor at rest!
and use a 1–1.5 mm smaller size
ETT than otherwise indicated.
Q: As you are assessing the child again, the mother mentions this is
their fourth visit to the ED for the same issue. When should you worry
about the child with recurrent croup?
A: Recurrent croup (three or more episodes) should be considered a red flag for
an alternative underlying cause. Anatomic abnormalities have been reported in
a significant proportion of patients with recurrent croup. Most, if not all, of these
patients will require bronchoscopy by ENT to rule out anatomic abnormalities.
228
KEY REFERENCES:
1. Rihkanen H, Rönkkö E, Nieminen T, et al. Respiratory viruses in laryngeal croup of young children.
J Pediatr. 2008; May;152(5):661-5,
2. Stoney PJ, Chakrabarti MK. Experience of pulse oximetry in children with croup. J Laryngol Otol.
1991; Apr;105(4):295-8.
3. Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral
dexamethasone for mild croup. N Engl J Med. 2004; Sep;351(13):1306-13.
4. Ledwith CA, Shea LM, Mauro RD. Safety and efficacy of nebulzie racemic epinephrine in
conjunction with oral dexamethasone and mist in the outpatient treatmen of croup. Ann Emerg
Med. 1995; Mar;25(3):331-7.
5. Prendergast M, Jones JS, Hartman D. Racemic epinephrine in the treatment of laryngotracheitits:
can we identify children for outpatient therapy? Am J Emerg Med. 1994; Nov;12(6);613-6.
6. Waisman Y, Klein BL, Boenning DA, et al. Prospective randomized double-blind study comparing
L-epinephrine and racemic epinephrine aerosols in the treatment of laryngotracheitis (croup).
Pediatrics. 1992; Feb;89(2):302-6.
7. Bjornson C, Russell K, Vandermeer B, Klassen TP, Johnson DW. Nebulized epinephrine for croup in
children (Review). Cochrane Database Syst Rev. 2013; Issue 10.
8. Moore M, Little P. WITHDRAWN: Humidified air inhalation for treating croup. Cochrane Database
Syst Rev. 2011; Issue 6.
9. Neto GM, Kentab O, Klassen TP, Osmond MH. A randomized controlled trial of mist in the acute
treatment of moderate croup. Acad Emerg Med. 2002; Sep;9(9):873-9.
10. Joshi V, Malik V, Mirza O, Kumar BN. Fifteen-minute consultation: structured approach to
management of a child with recurrent croup. Arch Dis Child Educ Pract Ed. 2014; Jun;99(3):90-3.
11. Rankin I, Wang SM, Waters A, Clement WA, Kubba H. The management of recurrent croup in
children. J Laryngol Otol. 2013; May;127(5):494-500.
229
CHAPTER 16:
PEDIATRIC SYNCOPE
LISTEN TO THE PODCAST WITH ERIC LETOVKSY AND ANNA JARVIS HERE
Objectives
1. Develop an approach to assessing a child who presents to the ED with syncope
2. Distinguish between syncope and seizure
3. Understand the key historical and physical exam features that distinguish
benign versus serious causes of syncope
4. Develop an approach to reading the ECG of a child who presents to the ED with
syncope
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CASE 1:
A STICKY LOC SITUATION
Sammy is a 15-year-old male out with his friends at a summer concert
watching a cool new band, The Crew, at the town festival. It is a hot
summer day. Sammy starts to feel warm and nauseated, and begins to
sweat profusely. Sammy loses consciousness and drops to the ground.
There are a few jerking movements of his limbs. He is unconscious
for only half a minute and quickly regains consciousness. His shirt is
soaked with sweat. When his friends question him, Sammy tells them he
remembers feeling warm and nauseated before he passed out, but does
not remember being unconscious. When you assess him in the ED he says
he feels fine, and his vital signs are all normal.
Q: What is your general approach to a sudden loss of

consciousness in a child?
A:
•• Step 1: Differentiate syncope from seizure
•• Step 2: Categorize syncope by the underlying cause as benign or
serious/life-threatening, and whether the cause is autonomic, cardiac, or
non-cardiac
•• Step 3: Assess the risk for a future cardiovascular event or sudden death
231
Step 1:
Q: Was Sammy’s episode at the concert a syncopal episode or a seizure?
A: Syncope is a symptom, not a diagnosis. It is characterized by a sudden loss of

consciousness as a result of decreased cerebral blood flow, with full recovery to a
baseline level of awareness within seconds to minutes. There are often a few jerking
limb movements associated with syncope as cerebral blood flow decreases, which can
be confused with seizure. Soft tissue injuries at multiple body sites, posturing, and a
rigid (tonic) phase before rhythmic activity (clonus) are more consistent with a seizure
than with syncope. Both syncope and seizure can cause urinary incontinence, but unlike
seizure, patients with syncope return quickly to a their baseline level of alertness.
Step 2:
Q: Was Sammy’s episode at the concert a syncopal episode or a seizure?
A: While Sammy’s episode is quite classic for vasovagal syncope, more serious causes
need to be ruled out.
Vasovagal syncope commonly presents with presyncopal symptoms—increased warm

or cold sensation, nausea, diaphoresis—occurring with prolonged standing (or changing
position from a lying or sitting position to a standing position), followed by a brief loss of
consciousness (usually between five and 20 seconds) with a quick resolution.
Patients with vasovagal syncope typically display pallor, with cold skin, profuse
diaphoresis, and occasionally dilated pupils. In general, this phase is not typically
recalled by the patient. Rarely, patients can describe feeling “disconnected” or being
able to hear bystanders’ voices while being unable to respond to them.
Clinical Pearl:
Vasovagal syncope almost never occurs in a supine position. In the supine

position, venous pooling is less likely to occur, which is a key mechanism
of vasovagal syncope.
232
Major Categories of Syncope
•• Vasovagal: Prodrome of nausea, presyncope, and sweating; triggered by

pain, anxiety, distress, or by prolonged standing or kneeling in a warm
and/or crowded place
•• Situational: Occurs with micturition, cough, defecation; or by carotid
sinus pressure (e.g., turning head, shaving), subclavian steal (e.g., during
arm exercises), or breath-holding spell
•• Orthostatic: Dehydration, alcohol, blood loss
•• CNS: Rarely the cause of syncope as the only symptom
•• Cardiovascular: Dysrhythmia, structural heart disease, or ischemia;
historical clues include a family history of sudden/unexplained death,
exertional syncope and no prodrome
Q: How is syncope evaluated in the pediatric population?
A: A detailed history and physical exam will identify the cause of syncope
in nearly 50% of the patients. A 12-lead ECG should be obtained in every
patient. Routine labs and neuroimaging are not recommended.
Q: We know that a good history is essential in evaluating

the child after a syncopal episode. What are some of the key
historical features that help distinguish benign from serious
causes of syncope?
A:
•• Pattern: Is this the first presentation, or is there a pattern of recurring
episodes?
•• Position: What position was the patient in?
•• Exertion: Was physical exertion involved?
•• Situation: What was happening at the time before syncope?
233
•• Signs/symptoms: Diaphoretic or dry; flushed, cyanotic, pallor, chest

pain, palpitations. What signs/symptoms was the patient experiencing
or was noticed by eyewitnesses?
•• Onset: How acute was the onset? Prodrome or acute?
•• Movements: Were there involuntary movements (jaw locking, tongue
biting)? When did the movements start (before, at, or after the onset of
syncope)?
•• Colour: What colour was the patient (pallor, flushed, cyanotic)?
•• Time: How long did the unconsciousness last (seconds or minutes)?
•• Recovery: Confusion versus no confusion: How aware was the patient
after? Was there confusion?
•• Injury: Did the patient sustain injury (e.g., tongue biting, multiple sites
of trauma)?
Q: Which groups of patients are considered high risk and need

further workup?
A: Patients presenting with any of the following require a thorough

evaluation to rule out potential cardiac or neurological cause of syncope:
1. Syncope during physical exertion

2. Family history of sudden cardiac death or deafness
3. Chest pain
4. History of structural heart disease
5. Abnormal cardiac exam
6. Focal neurological findings
The Modified Calgary Syncope Syndrome Score is a risk-stratification tool

that can help guide you in differentiating benign autonomic causes of
syncope from serious cardiac causes in children.
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Risk-Stratification Tool: Modified Calgary Syncope

Syndrome Score
1. Is there a history of bifascicular block, asystole, or supraventricular

tachycardia? (if yes, -5 points )
2. At times have bystanders noted that you turned blue during your faint?
(if yes, -4 points)
3. Did your syncope start when you were five years of age or younger? (if
yes, -3 points)
4. Do you remember anything about being unconscious? (if yes, -2 points)
5. Do you feel faint with prolonged sitting or standing? (if yes, +1 points)
6. Do you sweat before a faint? (if yes, +2 points)
7. Do you feel faint with pain or in medical settings? (if yes, +3 points)
A score of -2.5 has a sensitivity of 95.4% and specificity 67.7% for

differentiating cardiac syncope from neurocardiogenic syncope.
A score of -2.5 has a sensitivity of 96.3% and specificity of 72.7%

for differentiating cardiac syncope from postural orthostatic
tachycardiasyndrome (POTS).
A score lower than -3 means cardiac syncope should be considered.
Case resolution: The history is unremarkable for high-risk features.

Accucheck is 7.0 mmol/l. Orthostatic vitals are unremarkable. The
physical exam is unremarkable. ECG reveals normal sinus rhythm. A
urine drug screen was negative. Sammy is sent home with instructions
to keep well hydrated during such events and to find a place to sit or lie
down at the first signs of dizziness.
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CASE 2:
CENTREFIELD COLLAPSE
John is an athletic 14-year-old male who was out with his friends playing
football when suddenly he collapsed mid-stride. He spontaneously
recovered after about one minute. EMS was called and arrived on scene.
On route to the hospital, John told the paramedic that he felt some
chest pain and a bit short of breath before he collapsed. John further
explained that while working out last week at the gym, he felt chest pain,
which made him a bit dizzy. Sal, John’s father, arrived at the hospital and
mentioned that his brother suddenly died while playing hockey in his
30s, and his son suddenly collapsing reminded him of his brother’s story.
On physical exam, John was found to have an outflow murmur that
increases with valsalva. An ECG was ordered.
Q: What elements of this case are concerning for a cardiac

etiology?
A: The concerning elements of this case for a cardiac etiology are that John
collapsed while exerting himself physically, there was no prodrome, and
the syncopal event occurred mid-stride. His father, Sal, also tells of a family
history of his brother dying of sudden cardiac death at a young age.
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Clinical Pearl: Caution:
Syncope with cardiac etiology typically Any patient with abrupt

includes at least one of the following syncope with little or an
features which warrants further workup: absence of a prodrome
must undergo a more
1. Exertional syncope extensive evaluation
2. Chest pain, palpitations, dyspnea because of an increased risk
3. Abnormal physical exam: irregular of serious cardiac disease
rhythm, pathological murmur, and risk of future sudden
abnormal heart sound death.
4. Abnormal ECG
5. Cardiac family history: positive family
history or sudden cardiac death
before the age of 50
Key References:
In a recent large observational study of pediatric patients presenting to

the ED with syncope, a cardiac cause was found in 0.1%. Of these three
patients, syncope with exertion, preceded by palpitations, and absence of
prodrome were the most significant historic features. The presence of at
least two features yielded a sensitivity of 100% and a specificity of 100%
for syncope having a cardiac etiology.
237
John’s history is worrisome for cardiac pathology as

a cause of his syncope.
Clinical Pearl: Q: How can the physical exam help you

An outflow murmur differentiate the serious causes of syncope?
that increases with
valsalva or standing A: An outflow murmur that increases with valsalva
is hypertrophic or standing is hypertrophic cardiomyopathy (HCM)
cardiomyopathy until proven otherwise. Another etiology of syncope
until proven that can occur with exertion and reveals an outflow
otherwise. murmur that is important to recognize is aortic
stenosis.
HCM is one of the most common inherited cardiac

disorders (affecting ~ 1 in 500 people) and is the
number one cause of sudden cardiac death in young
athletes. Hypertrophic obstructive cardiomyopathy
(HOCM) is a subset of HCM and is characterized by
left ventricular outflow tract obstruction—systolic
anterior motion of the mitral valve and impingement
on the hypertrophied basal septum. In the majority
Clinical Pearl:
of cases (75%), HCM is not associated with left
Signs of serious ventricular outflow obstruction.
physical injury on
physical exam, such Aortic stenosis is another cause of syncope that can
as facial trauma occur with exertion. A mid-systolic ejection murmur
or head injury, are is heard at the right upper sternal border, with
more suggestive of radiation into the neck. The murmur decreases with
a serious cardiac valsalva or standing, and increases with handgrip
etiology. or squatting. The murmur of aortic stenosis has the
opposite characteristics of the murmur heard in
HCM.
238
Q: We know that an ECG is the single most important test in evaluating

patients after a syncopal episode. What is your general approach to
interrogating the ECG of a patient who has a history of syncope?
A: The intervals to interrogate on the ECG of patients

who present to the ED with syncope:
•• PR interval: Clinical Pearl:

•• Short PR: Wolff-Parkinson-White (WPW)
syndrome ECG interpretation
•• Long PR: AV conduction block in patients who
present with syncope
•• QRS interval: is all about the ECG
•• Narrow, deep QRS: Hypertrophic obstructive intervals!
cardiomyopathy
•• Wide QRS: Ventricular tachycardia, WPW
syndrome
•• Wide QRS + epsilon waves: Arrhythmogenic Plus interrogate the ECG for:
RV hypertrophy 1. Brugada syndrome
2. Ischemia
•• QT interval: 3. Pulmonary embolism
•• Long QT syndrome, short QT syndrome
Caution:
Commotio cordis is a life-threatening dysrhythmia causing cardiac arrest,

often confused with syncope. The cause is a direct, non-penetrating, low-
impact blow to the chest, directly over the heart (the precordial region), at
a critical time during the heart cycle. Commotio cordis often occurs during
sporting events, but has been reported to occur as a result of abuse, fighting,
snowballs, and hollow plastic toys. Ventricular fibrillation is the most common
dysrhythmia, but heart block, ventricular tachycardia, bundle branch block, ST
abnormalities, and asystole can occur.
239
Q: What do you expect the ECG to look like in patients with HCM?
A: ECG findings of HCM include:

•• Increased QRS complex voltage (“Dagger-Like Q waves”)
•• ST-segment and T-wave signs of LV hypertrophy
•• Q-waves in leads II, III, aVF, V5, V6
ECG showing signs of HCM: Dagger-like Q waves in inferior and lateral

leads. Courtesy of Life in the Fast Lane blog.
Caution:
HCM is the most common cause of sudden death during exercise in

young adults and children!
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Q: What else can be done at the bedside to support your

diagnosis of HOCM?
A: Bedside ultrasound can reveal a dilated, hypertrophic myocardium.

Assessment for fluid status evaluation (IVC), tamponade/contractility
(cardiac), and free fluid in the abdomen can rule in or rule out other causes
of syncope.
Video: Click here to watch a video of HOCM on echocardiography.
Q: What is arrhythmogenic right ventricular cardiomyopathy

(ARVC), and what are the typical ECG findings?
A: ARVC is a genetic disorder leading to cardiac fibro-fatty changes, which

may result in sudden cardiac death in young people.
The classic ECG findings of ARVC are:

•• Inverted T waves in right precordial leads (V1, V2, V3)
•• QRS in Lead 1 > 110 msec
•• Epsilon waves (low amplitude notches after QRS and before T wave) in
the right precordial leads (V1- V3)
241
Q: Is benign early repolarization (BER) really benign?
A: BER is common in young, otherwise healthy people and has historically

been considered to portend no significant clinical sequelae. However,
recently a BER pattern in the inferolateral leads has been found to be
associated with ventricular fibrillation in a small subset of patients.
Consider referring patients with a BER pattern in the inferolateral leads
who present to the ED with syncope to a cardiac electrophysiologist.
ECG showing a benign early repolarization pattern in the inferolateral leads.

This pattern may predispose patients to ventricular fibrillation.
Clinical Pearl:
Acquired heart block found on ECG can be caused by infectious myocarditis
(most commonly Lyme disease), neonatal lupus, congenital heart disease,
or cardiomyopathy. Second- and third-degree heart block in the setting of
syncope usually requires urgent placement of a cardiac pacemaker.
242
Q: How would you describe an ECG with WPW characteristics?
A:
•• Short PR interval of less than three small squares (120 ms)
•• Slurred upstroke to the QRS indicating pre-excitation (delta wave)
•• Broad QRS
•• Secondary ST and T wave changes
ECG showing WPW syndrome. Courtesy of Life in the Fast Lane blog.
Clinical Pearl:
Atrial arrhythmias are rarely associated with syncope, with the important
exception of WPW syndrome.
243
Q: What is the typical story of a patient who suffers a syncopal

episode as a result of long QT syndrome?
A: The history of pediatric patients who present to the ED with syncope

related to long QT syndrome typically involves exertion such as swimming,
or emotional distress. These patients can also suffer an abrupt onset of
syncope due to fright or awakening by a loud noise, such as an alarm clock.
Congenital long QT is often associated with congenital deafness. Many
medications as well as hypokalemia, hypocalcemia, and hypomagnesemia
can result in a prolonged QT interval that may trigger the syncopal episode.
Normal ECG versus ECG with long QT, Courtesy of www.washingtonhra.com.
Clinical Pearl:
While a QTc interval > 500 is considered high risk for Click here for a list
torsades de pointes and sudden death, in children a QTc of medications to
interval > 450 is considered high risk warranting referral to avoid in patients
an cardiac electrophysiologist. with long QT.
Short QT syndrome (QTc < 340, or < 360 in patients with a

family history of sudden death) is also a rare but lethal ECG
finding, and must be investigated.
244
Long QT leading to torsades de points
Q: Can Brugada syndrome occur in children?
A: Brugada syndrome is rare in children. It usually occurs in adulthood

between the ages of 22 to 65. An Ajmaline challenge test at the start
of puberty in asymptomatic patients with a family history of Brugada
syndrome can unmask Brugada ECG changes. Brugada ECG changes are
more likely to occur during febrile illnesses.
Caution:
Sudden cardiac death may be the first and only presenting symptom of
Brugada syndrome.
245
Clinical Pearl:
The ECG of a patient with Brugada syndrome is divided into two types:
•• Type 1 shows a pseudo-RBBB pattern with a triangular-shaped ST
elevation in the anterior precordial leads (V1 to V3)
•• Type 2 shows a > 2mm of saddleback-shaped ST elevation
Type 1 Brugada sign
Type 2 Brugada sign. Courtesy of Life in the Fast Lane blog.
246
Q: What lab tests would you consider ordering in a patient with syncope
who has an ECG showing a prolonged QT interval?
A: Routine blood tests are of low diagnostic value in patients who present to
the ED with syncope. However, in a patient whose ECG shows a prolonged QT
interval, an electrolyte panel may be revealing as hypokalemia, hypocalcemia, and
hypomagnesemia can all cause a prolonged QT interval.
Caution:
Some of the more common medications that can prolong the QT interval
include the following:
•• Tricyclic antidepressants •• Macrolide antibiotics
•• Antipsychotics •• Antihistamines
CASE 3:
BREATHLESS & BLUE
Sarah is a 14-month-old girl brought in to the ER by her nanny after “fainting”
this afternoon. Sarah was playing with the household cat, Patches, when the
cat swatted and scratched her arm. Sarah gave a loud cry and then stopped
breathing, according to the nanny. She then turned pale, then blue, and her body
jerked a couple of times before going limp. After about 30 seconds, Sarah gasped
for air, followed by a few deep inspirations, and she returned to normal.
Q: What are the two main types of breath holding spells and how do they
present?
A: Breath-holding spells are seen in children between six months and 24 months
of age. There are two forms, cyanotic and pallid. The cyanotic form occurs at six
months of age, peaks at two years, and is completely gone at 5 years. The episode is
247
brought on by injury or pain resulting in a loud

cry followed by apnea. The pallid form occurs
between 12 months and 24 months, and is
also brought on by injury or pain, similar to the
cyanotic form. There is no crying (in contrast to
the cyanotic form) and the loss of consciousness
occurs quickly. No treatment is required.
In the cyanotic form, the child turns pale or

cyanotic. There may be jerky or myoclonic
movements followed by the body going limp.
The entire episode lasts less than one minute.
Want more syncope stories?
In the pallid form, the child turns pale and Listen to Dr. Jarvis’ Best Case
hypotonic, and develops rhythmic muscle Ever for more helpful tips and
contractions. On cardiac monitoring, the memorable stories!
episodes are associated with bradycardia and/or
asystole.
Clinical Pearl: Comments?

Cough can cause syncope called tussive comment or to listen to
syncope. It is often associated with this podcast.
bronchospasm from acute infection,
asthma, pertussis, or cystic fibrosis.
The paroxysms of coughing cause high
intrathoracic pressure and reduced
cardiac output.
248
KEY REFERENCES:
1. Kaniwal K, Calkins H. Syncope in children and adolescents. Cardiol Clin. 2015; Aug;33(3):397-409.
2. Tretter JT, Kavey RE. Distinguishing cardiac syncope from vasovagal syncope in a referral
population. J Pediatrics. 2013: Dec;163(6):1618-23.
3. Yang J, Zhu L, Chen S, et al. Modified Calgary score in differential diagnosis between cardiac
syncope and postural orthostatic tachycardia syndrome-associated syncope in children. Cardiol
Young. 2013; Jun23(3):400-4.
4. Timmermans C, Smeets JL, Rodriguez LM, Vrouchos G, van den Dool A, Wellens HJ. Aborted
sudden death in Wolf-Parkinson-White syndrome. Am J Cardiol. 1995; Sep;76(7):492-494.
5. Brugada J, Brugada R, Brugada P. Right bundle branch block and ST segment elevation in leads V1
through V3. Circulation. 1998; Feb;97(5):457-60.
6. Prodinger RJ, Reisdorff EJ. Syncope in children. Emerg Med Clin North Am. 1998; Aug;16(3):617-26.
7. Maron BJ. Hypertrophic cardiomyopathy: a systematic review. JAMA. 2002; Mar;287(10):1308-20.
8. Maron BJ. Sudden death in young athletes. N Engl J Med. 2003; Sep;349(11):1064-75.
9. Gersh BJ, Maron BJ, Bonow RO, et al. ACCF/AHA guidelines for the diagnosis and treatment
of hypertrophic cardiomyopathy: a report of the American College of Cardiology Foundation/
American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2011; Dec;58(25):
2703-38.
10. Probst V, Denjoy I, Meregalli PG, et al. Clinical aspects and prognosis of Brugada syndrome in
children. Circulation. 2007; Apr;115(15):2042-8.
11. Haïssaguerre M, Derval N, Sacher F, et al. Sudden cardiac arrest associated with early
repolarization. N Engl J Med. 2008; May;358(19):2016-23
12. Hurst D, Hirsh DA, Oster ME, et al. Syncope in the pediatric population emergency department --
can we predict cardiac disease based on history alone? J Emerg Med. 2015; Jul;49(1):1-7
13. DiMario FJ. Prospective study of children with cyanotic and pallid breath holding spells. Pediatrics.
2001; Feb;107(2):265-9.
14. Steinberg LA, Knilans TK. Syncope in children: diagnostic tests have a high cost and low yield. J
Pediatr. 2005; 146:355-8.
15. Zangwill SD, Strasburger JF. Commotio cordis. Pediatr Clin North Am. 2004; Oct;51(5):1347-54.
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CHAPTER 17:
PEDIATRIC SEIZURES
LISTEN TO THE PODCAST WITH LAWRENCE RICHER & ANGELO MIKROGIANAKIS HERE
Objectives
1. Differentiate between benign febrile seizures and complex febrile seizures
2. Learn the appropriate workup for both febrile and non-febrile seizures
3. Review the management of seizures in the emergency department
4. Know the medication options for status epilepticus
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CASE 1:
THE BLUE CHILD
A 14-month-old boy is brought in by his mother as she is worried that he had
a seizure at home. He was playing quietly on the living room floor and his
mother stepped briefly into the kitchen. She heard a bang, then a cry, and
went running into the room to find her son lying on the floor looking a bit
blue. He made a couple of jerky movements and then started to move and
breathe normally. After the episode, he woke up within minutes and was
completely back to normal on arrival in the ED. His vital signs were normal
and he was happily playing with his mother in the examination room.
Q: How can we determine if what parents witnessed at home was

truly a seizure? What conditions can be mistaken for seizure?
A: Much of this is going to hinge on the history. Ask about the onset; duration
and nature of the movements; tongue biting; eye findings and the recovery
phase after the episode. The level of responsiveness during the episode is
also important, as parents can sometimes mistake rigors for seizure activity.
The recovery phase is critical, as a rapid/immediate return to normal activity
is unlikely to follow a true seizure. Breath-holding spells, syncope, and
pseudoseizures can be difficult to differentiate from true seizures.
Clinical Pearl:
Elements highly suggestive of seizure activity include:
•• Postictal phase
•• Lateral tongue biting
•• Flickering eyelids
•• Blank stare or deviated eyes
•• Lip smacking
•• Increased heart rate and blood pressure during the event
251
Q: This child turned blue, which can be seen with a breath-

holding spell. How do you distinguish breath-holding spells
from true seizures?
A: Breath-holding spells are most common in the six-to-18-month age

range. Usually there is a clear trigger, such as emotional distress or pain.
The episode can still involve very brief seizure activity due to temporary
decrease in cerebral oxygenation. Recovery is rapid and complete as there
is no postictal phase.
Q: Could this 14-month-old have had a pseudoseizure? How do

you distinguish pseudoseizures from true seizures?
A: Pseudoseizures tend to be seen in the adolescent population since

younger children cannot feign seizure activity for secondary gain. As such,
this 14-month-old did not have a pseudoseizure. Pseudoseizures can be
difficult to distinguish from true seizures, particularly on history. They are
often easier to diagnose if witnessed directly in the emergency department.
Movements may include side-to-side motion of the head, back arching,
asynchronous movements (e.g., bicycling). The level of consciousness may
be preserved and patients may respond during the episode.
Q: On further questioning the parents, there is a family history of

sudden death at an early age, and you wonder whether this child
could have suffered a syncopal episode rather than a seizure.
How do you distinguish syncope from true seizure?
A: In a syncopal episode, loss of consciousness precedes any abnormal

movements. The patient may have a few myoclonic twitches but should not
have ongoing tonic-clonic movements. Recovery is rapid and complete.
For more on pediatric syncope, go to Chapter 16: Pediatric Syncope.
252
CASE 2:
FEBRILE SEIZURES
Panicked parents bring their eight-month-old to your Emergency
Department. Thirty minutes ago, they saw their daughter suddenly become
unresponsive and start shaking. The episode lasted about five minutes, and
the child is now waking up. They mention that she has had a fever for the
past four days and they have been giving her acetaminophen for this at
home. She has not had any respiratory or GI symptoms over the past few
days. She is otherwise healthy and fully immunized.
On exam, the child is awake but a bit drowsy. She has moist mucous membranes
and normal capillary refill. Her neck is supple, she is moving all four limbs well
and is beginning to interact with her parents. Her vital signs are normal other
than a temperature of 38.3°C. Her ENT and respiratory exams are normal and
her abdomen is benign. She does not have a rash. As you are examining her, she
begins to seize again.
Q: You are convinced by both the history and seizure you see in the
emergency department that this child has had a seizure associated with
a febrile illness. The distinction between simple versus complex febrile
seizures is important, as complex febrile seizures may indicate a more
serious underlying disease process and warrant a workup. How do you
distinguish simple from complex febrile seizure clinically?
A: A diagnosis of complex febrile seizures is made if there is any deviation from the
criteria of a simple febrile seizure.
253
Clinical Pearl:
Simple febrile seizures tend to occur within the first 24 hours of a febrile
illness. If the seizure occurs > 24 hrs after the onset of fever as in this case,
the index of suspicion for a serious bacterial illness should be heightened.
Q: A repeat temperature is Q: You’ve decided that this child has

taken that shows a temp suffered a simple febrile seizure. Does
of 39.7°C. The parents are she require blood work? Urinalysis?
very concerned about the X-rays? What workup is required for a
“dangerously high fever.” patient with a simple febrile seizure?
Does the height of the fever
correlate with the chances of A: No dedicated seizure workup is required
having a febrile seizure? for simple febrile seizures. The workup should
focus on looking for the source of the fever, and
A: The height of fever does the approach should be the same as if the child
not correlate with seizures; had only the fever with no seizure. The child
however, the rapidity of the rise in with a simple febrile seizure is at no greater risk
temperature is thought to correlate for serious bacterial infection than age-matched
with the occurrence of seizures. controls with fever who have not seized.
For more on pediatric fever go to Chapter 1 on Fever Without a Source.
Q: What workup is required for a patient with a complex febrile seizure?
A: The workup of complex febrile seizures requires a stepwise approach given the wide
breadth of presentations in this category. Keep in mind that the younger the child, the more
aggressive the workup should be. Children who return to baseline after a complex seizure
and at no point displayed any focal neurologic symptoms usually do not require an extensive
workup. Even though studies have shown that febrile seizures do not increase the risk of
serious bacterial infection compared with fever alone, meningitis should always be on the
differential diagnosis in a child with complex febrile seizures. About 25% of children with
meningitis will present with a new onset febrile seizure; however, they will almost always
display persistent mental status abnormalities along with other signs of meningitis, such as
nuchal rigidity, focal seizures, and petechia.
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If the seizure was focal, one should consider CNS infection, neuroimaging,
and EEG testing. Otherwise, in the child older than six months who has had
somewhat prolonged or multiple seizures in 24 hours, a combination of
limited testing and observation with frequent reassessment is reasonable.
Initial tests generally include CBC, glucose, electrolytes, and urinalysis.
Q: Let’s say that this child looked toxic after a complex febrile
seizure. Would you perform a lumbar puncture? What are the
indications for doing a lumbar puncture in a child with a febrile
seizure? Would you send the patient for a CT scan of the head?
When would you consider neuroimaging in the ED in the child
with a febrile seizure?
A: There is no clear, exhaustive list of indications for doing a lumbar

puncture, so some clinical judgment must be used.
BMJ Article on
Febrile Seizures (2015)
Red flags to warrant considering a
lumbar puncture: Indications for neuroimaging in the
ED in the child with a febrile seizure:
•• Postictal symptoms lasting > one
hour •• Suspicion of non-accidental injury
•• Any physical exam signs of •• Signs of increased ICP
meningitis (bulging fontanelle, neck •• Patient who does not return to
stiffness, focal neurologic deficits, neurologic baseline
photophobia, petechial rash) •• Underlying known CNS disorder
•• Irritability or lethargy (e.g., VP shunt)
•• Already on antibiotics
•• Incomplete immunization (HiB and
Strep pneumo)
•• Complex febrile seizures
255
Q: You diagnose this child with a viral illness and simple febrile
seizure and decide to send her home. What discharge instructions will
you give the parents?
A:
Safety: Place the child in the recovery position and do not place anything in the
child’s mouth
Risk of recurrence is approximately 33% overall, with a higher risk in children

with these risk factors:
•• Younger than 18 months
•• Temperature < 40.0°C at first convulsion
•• Less than one hour between onset of fever and first seizure
•• Family history of febrile seizures
If the child has all four of the risk factors, the risk of recurrence is 70%. If the
child doesn’t meet any criteria, the risk falls to 20%.
Risk of epilepsy is approximately 2% after a simple febrile seizure and 5% after a

complex febrile seizure (compared with 1% in the general population)
Q: As you’re about to discharge this child, the parents ask you about
how to keep the child’s fever at bay to prevent another seizure from
occurring. Does the use of antipyretics alter the risk of febrile seizure?
A:
Clinical Pearl:
Parents will often blame themselves for not treating the seizure
appropriately or quickly enough to prevent the seizure. It is important to
educate them that the height of the fever does not predict risk of suffering a
seizure, and that prophylactic antipyretics do not have any effect on the rate
of seizure recurrence.
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CASE 3:
NON-FEBRILE SEIZURE
A two-month-old girl is brought in to the ED by her
parents. Over the past 24 hours she has become
increasingly drowsy. She has no fever, respiratory
symptoms or GI symptoms. Thirty minutes ago,
the parents witnessed what you determine to
be a generalized tonic-clonic seizure lasting two
minutes. She is now beginning to rouse. The infant
was born at term with no issues during pregnancy
or with the delivery. She is otherwise healthy.
There is no family history of seizure disorders.
On exam, the infant is drowsy but rousable, and

has reasonable tone. Her mucous membranes Café au lait spots
are moist and capillary refill is normal. Vitals are
normal and her rectal temperature is 36.1°C.
Her ENT, chest, abdominal, and skin exams are
unremarkable.
Q: What specific physical exam findings are

you looking for when you examine this two-
month-old girl after her non-febrile seizure?
A: The physical exam is tailored to looking for

potential underlying causes for the seizure:
Skin: Look for lesions such as café au lait spots

(neurofibromatosis), angiofibromas or ash leaf spots
(tuberous sclerosis), or port-wine stains (Sturge-
Weber syndrome). Unexplained bruising raises
suspicion for bleeding diathesis or non-accidental
injury.
Port-wine stain
257
Angiofibromas
Eyes: Papilloedema and retinal hemorrhages Papilledema and retinal hemorrhages
Head: Bulging fontanelle, head circumference, dysmorphic features, signs of trauma
Neck: Signs of meningeal irritation
Abdomen: Hepatosplenomegaly may indicate a metabolic or glycogen storage disease
Pitfall:
Children younger than two years of age who present to the ED with a non-
febrile seizure are almost always found to have a worrisome underlying
etiology, as apposed to epilepsy. Even if the history and physical do not
reveal any obvious etiology for the seizure, these patients need further
assessment to rule out ominous causes of their seizure.
Q: Does this child require laboratory studies in the ED?
A: Lab tests may not be necessary for the child who has suffered a brief seizure and is
now alert and back at baseline level of function. A thorough history and physical exam in
patients who have no identifiable risk factors have been shown to yield more diagnostic
information than a laboratory evaluation.
258
Consider ordering labs on patients who:

•• Suffer prolonged seizures
•• Are younger than six months of age
•• Have a history of diabetes, metabolic disorder, dehydration, or excess
free water intake
•• Have a persistent altered level of awareness or other neuro deficits
•• Are taking an anticonvulsant medication whose serum levels can be
assessed
Q: Which laboratory studies are Q: Would you order a CT scan on this two-
required in the ED? month-old girl who has suffered a non-febrile
seizure? Why or why not?
A: Specific laboratory tests should
be guided by the clinical assessment. A: Neuroimaging is generally not necessary in
Some tests to consider are: the ED in a child after a non-febrile seizure who
•• Capillary glucose returns to neurologic baseline. This child has not
•• CBC returned to her baseline level of awareness, and so
•• Electrolytes including sodium, neuroimaging might be a reasonable consideration.
calcium, and magnesium
•• Ammonia (for inborn errors of Some high-risk criteria for finding a culprit lesion on
metabolism) a CT scan of the head are:
•• Toxicology screen •• Focal seizure or persistent seizure activity
•• Serum level of anticonvulsant •• Focal neurologic deficit
(if patient is already on an •• VP shunt
anticonvulsant medication) •• Neurocutaneous disorder suggested on skin
•• ECG (if you are considering exam
syncope for a cardiac cause of •• Signs of elevated increased ICP
event; e.g., long QT) •• History of trauma
•• Travel to an area endemic for neurocysticercosis
•• Immunocompromised state
•• Hypercoagulable state (e.g., sickle cell disease)
or bleeding disorder
259
Q: The head CT is interpreted as normal and the laboratory tests

come back showing a serum sodium level of 115. What is the
most likely cause of this child’s seizure?
A: The differential diagnosis of non-febrile pediatric seizures is extensive,

encompassing metabolic derangements to mass lesions to non-accidental
trauma. However, in this case the most likely cause is hyponatremia
secondary to over-dilution of infant formula.
Clinical Pearl:
One particular diagnosis that is one of the more common causes of

non-febrile seizure in children younger than six months of age and is
relatively easy to pick up (thus avoiding an extensive invasive workup) is
hyponatremia secondary to formula over-dilution. In a paper from the
Annals of Emergency Medicine, hyponatremia was the cause of seizures
in 70% of 47 infants younger than six months of age who lacked other
findings suggesting a cause.
On further questioning, you find out that this child’s parents have indeed
been watering down the infant formula.
Q: You decide to consult the pediatric team. While you are

waiting to for them to arrive, the child seizes again. What
medications will you administer to this child besides the usual
benzodiazepines?
A: For children with seizures as a result of severe hyponatremia, 3 cc/kg of

hypertonic (3%) saline IV bolus is recommended.
260
Q: While this child requires admission to hospital, some children

who have suffered a non-febrile seizure can be discharged home
safely. Which children can be safely discharged from the ED after a
non-febrile seizure?
A:
< Six months: Six to 24 months: > 24 months:

Generally Disposition will Those who have returned to
require a full depend on blood baseline and have a normal
workup and are work, reassessment, neurological exam with
usually admitted and the ability to normal workup are often
for observation. have close follow-up safe to be discharged to
for an EEG +/- MRI. close outpatient follow-up
for EEG +/- MRI. Otherwise,
admit.
Q: Suppose that this patient was not found to have any underlying
etiology for her non-febrile seizure. What is the risk of recurrence
after a non-febrile seizure?
A: Approximately 50% of patients with first episode non-febrile seizure will

have a recurrent seizure. The decision to start an anticonvulsant medication
will generally not be made in the ED. Arrange follow-up either with general
pediatrics or pediatric neurology, who will usually do an EEG and possibly an
MRI in order to risk-stratify those who may require anticonvulsant medications.
261
CASE 4:
STATUS EPILEPTICUS
A three-year-old boy is brought in by an EMS crew. The mother called 911
after her son seized at home, and en route to hospital the child began to
seize again. By the time they arrive in your ED the child had been seizing
continuously for eight minutes.
Q: What are your initial priorities in the management of this case?
A: Initial interventions include:

1. Evaluation of the airway and administration of supplemental oxygen
2. Administration of antiepileptic agents
3. IV/IO access
4. Cardiac monitoring
Q: This child has been seizing for eight minutes. Does this
constitute status epilepticus? How is status epilepticus defined?
A: Status epilepticus has traditionally been defined as seizure activity lasting

more than 30 minutes. However, recently a more practical and conservative
definition has been accepted by the emergency medicine community:
1. Seizure lasting more than five minutes, OR
2. Consecutive seizures without a return to baseline in between
262
Pitfall:
A common pitfall in the management of seizures is delayed

administration of benzodiazepines. Complications of prolonged
seizures include hypoxia, lactic acidosis, rhabdomyolysis, hyperkalemia,
hyperthermia, and hypoglycemia, along with permanent neurologic
damage. Status epilepticus also becomes progressively more resistant
to anticonvulsant drugs over time, so prompt recognition and
treatment are paramount.
Q: This child has no IV access and is still

seizing. His parents are freaking out,
the resuscitation room is teeming with
Clinical Pearl: people, and your heart rate has gone
way up. You know this child needs a
Essentially, if a child is benzodiazepine. What is the best way to
still seizing on arrival to deliver the first dose of benzodiazepine?
hospital, treat as status
epilepticus. A: The priority is to get a dose of a
benzodiazepine into the patient as quickly as
possible. Often, attempting to get an IV in an
actively seizing child is difficult and can delay the
delivery of drugs. There are many alternative
routes available (intramuscular, intraosseous,
Clinical Pearl:
intranasal, buccal, rectal) that require slightly
different dosing of the various benzodiazepines.
Early administration
Rectal diazepam is helpful outside of the
of benzodiazepines
hospital setting, but in hospital IM, IN, or buccal
is a priority in status
midazolam or lorazepam are preferred due to
epilepticus.
their rapid onset of action.
263
Benzodiazepine Dosing
The choice of benzodiazepine and the choice of route are not the major
determinants of efficacy. Rather, the most important determinant of
benzodiazepine efficacy in stopping seizures is time to administration. Again,
early administration of a benzodiazepine is a priority.
Q: Another priority in the management of status epilepticus is looking

for an underlying cause. What are the causes of status epilepticus
that require specific treatment beyond (or instead of) anticonvulsant
medications?
A: There are a number of specific situations that require specific treatment. Some
can be established on history and others will require specific laboratory tests.
Pitfall:
All seizing children should get a capillary glucose measurement early in

their assessment to check for hypoglycemia as a cause for the seizure.
264
Some important specific causes of seizures and their treatments are as follows:
Cause Treatment
Hyponatremia 3 cc/kg of hypertonic (3%) saline IV
Hypoglycemia Dextrose IV
Anticholinergic toxicity Sodium bicarbonate (if QRS > 100)
Isoniazid toxicity Pyridoxine
Eclampsia Magnesium Sulphate
Clinical Pearl:
Once you have started giving your antiepileptic medications, start drawing
up the next dose of medication so it is ready to administer if seizure
activity continues to persist.
Q: This child received two doses of diazepam but continues to seize. What is
your next move?
A: Generally, the second-line drug would be fosphenytoin or phenytoin. If fosphenytoin is

available, this is preferred over phenytoin because of the reasons listed below.
Caution:
Avoid using phenytoin/fosphenytoin in toxin-related seizures (e.g., cocaine,
local anesthetics, theophylline, TCAs). If you are suspicious of a toxin-related
seizure, consider using phenobarbital or valproate as second-line drugs.
265
Q: When would you consider using phenobarbital instead of

fosphenytoin/phenytoin as a second-line drug?
A: There are a few situations in which phenobarbital is preferable to

phenytoin/fosphenytoin:
•• Neonatal seizures
•• Febrile seizures
•• Patient with previous SE responsive to phenobarbital
•• Toxin-related seizure
Q: You have given three doses of benzodiazepines and a

fosphenytoin load, and the patient is still seizing. This is now
refractory status epilepticus. What are your next moves?
A: If the patient is still seizing and has not already been intubated, the
airway should be secured. In terms of medications, the options include an
infusion of midazolam, pentobarbital, or propofol.
Status Epilepticus Algorithm
266
Q: Your job is not over yet. What are your priorities of

management once this child has finally stopped seizing?
A: A full reassessment and management of the ABCs would be the first

priority. If the patient is not already intubated, consider definitive airway
management depending on clinical assessment. Monitor and manage
bradycardia, hypotension, and hypoxia. If you are not in a hospital that has
a PICU, arrange transport to a tertiary pediatric centre.
The next priority is to identify any underlying causes for the seizure if it
hasn’t been identified already. Double-check blood work, including sodium
and calcium levels. Do an ECG to look for evidence of toxins or primary
cardiac causes of the event (e.g., long QT). Think about other reversible
causes, such as hypertensive encephalopathy, structural CNS disease, non-
accidental injury, toxins, etc.
Comments?

When was the last time you saw ventricular this podcast.
fibrillation in a 4 month old? Listen to Dr.
Rob Simard’s Best Case Ever of a Pediatric
Cardiac Arrest.
267
KEY REFERENCES:
1. Alford EL., Wheless JW, Phelps SJ. Treatment of Generalized Convulsive Status Epilepticus in
Pediatric Patients. J Pediatric Pharmacol Ther, 2015; 20(4):260-89.
2. Berg AT, Shinnar S, Darefsky AS, et al. Predictors of recurrent febrile seizures. A prospective
cohort study. Arch Pediatr Adolesc Med. 1997; Apr;151(4):371-8.
3. Hirtz D, Berg A, Bettis D, et al. Practice parameter: Treatment of the child with a first unprovoked
seizure Report of the Quality Standards Subcommittee of the American Academy of Neurology
and the Practice Committee of the Child Neurology Society. Neurology. 2003; Jan;60(2):166-75.
4. Larry. Seizures and Status Epilepticus: Diagnosis and Management in the Emergency Department.
2007; 1–32.
5. Patel N, Ram D, Swiderska N, Mewasingh LD, Newton RW, Offringa M. Febrile seizures. BMJ. 2015;
Aug; 351:h4240.
6. Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus Intravenous Therapy for
Prehospital Status Epilepticus. N Engl J Med. 2012; Feb;366(7):591-600.
7. Subcommittee on Febrile Seizures, American Academy of Pediatrics. Neurodiagnostic evaluation
of the child with a simple febrile seizure. Pediatrics. 2011; Feb;127(2):389-94.
8. Warden CR, Brownstein DR, Del Beccaro MA. Predictors of Abnormal Findings of Computed
Tomography of the Head in Pediatric Patients Presenting With Seizures. Ann Emerg Med. 1997;
Apr;29(4);518-23.
268
RAPID REVIEW
QUESTIONS
TEST YOUR NEW KNOWLEDGE IN A FUN

RAPID REVIEW
QUESTION-BASED FORMAT
269
CH. 1: PEDIATRIC FEVER WITHOUT A SOURCE

Q: What rule can we use to correct for a child’s heart rate and respiratory
change in the setting of a fever? Apply this rule in a 12-month old girl
who presents to your ED with a rectal temp of 39.0°C, heart rate 125 and
respiratory rate of 25.
A: Heart rate: increases by 10 beats per minute for every degree of fever above 38°C
Resp rate: increases by 5 breaths per minute for every degree of fever above 38°C
Corrected HR = 125 – (10 x 1) = 115

Corrected RR = 25 – (5 x 1) = 20
Q: Which two vaccines are the most important in reducing rates of

bacteremia is children and at which ages are they given?
A: Haemophilus influenzae type b and Pneumococcal conjugate vaccine. There is

a very low rate of bacteremia in children with 2 or more doses these two vaccines.
In Canada, the Haemophilus vaccine is given at 2, 4, 6 and 18 months and the
Pneumococcal vaccine is given at 2, 4, and 12 months.
Q: An 18 month old child presents to your emergency department with a

fever without an obvious source after your initial assessment. What are
the 5 most common sources of fever you consider in this age group?
A: LUCAS mnemonic: Lung, urine, CNS, abdomen, skin
Q: What are risk factors for a UTI in the pediatric population?
A: The risk factors for UTI are:

•• Females < 24 months
•• All males < 6 months
•• Uncircumcised males < 24 months
•• Fever for more than 2 days or fever > 39°C
•• History of previous UTI
270
CH. 1 CONT’D: FEVER WITHOUT A SOURCE

Q: If you suspect a UTI in a child, how do you decide when to use a bag
vs. catheter vs. midstream urine in a child based on the age of the child?
A: < 2 months: obtain urine sample by catheterization and send every sample for a
culture (as the urinalysis may be normal with a true infection)
2 months until toilet trained: bag urine is acceptable to screen by microscopy, if

positive (ie. > 10-20 WBCs/hpf) a catheter sample is necessary
Toilet trained: obtain a mid-stream urine after adequate cleaning of the genitals.
Q: Which children require additional urological imaging after a diagnosis

of UTI?
A: All children < 2 years with a first time UTI should have an outpatient ultrasound to
look for vesico-ureteral reflux and structural anomalies. A voiding cysto-urethrogram
(VCUG) is no longer recommended for children with a first time UTI.
Q: What does a full septic workup include and what age group is this
recommended in?
A: A full septic workup is recommended in infants under 28 days of age. It includes:

•• CBC
•• Blood cultures
•• Urinalysis collected by catheter
•• Urine culture
•• CSF sampling (send for: cell count, culture, gram stain, protein, glucose and viral
studies)
271
CHAPTER 2: PEDIATRIC SEPSIS & SEPTIC SHOCK
Q: Is hypotension necessary for you to make the diagnosis of sepsis?
A: Absolutely not. Hypotension is a late sign of pediatric septic shock and imminent
arrest. Do NOT wait for hypotension to make the diagnosis of septic shock.
Q: You should quickly move to place an intraosseous line in your

critically ill child if obtaining IV access is delayed by how long?
A: If your team cannot obtain IV access within the first 6o seconds, put in an IO line.
Q: If you have made the call that your critically ill child is in septic shock,
how much fluid should you be giving as an initial resuscitative measure?
A: Fluids, typically crystalloids such as normal saline or Ringer’s lactate, are given in
boluses of 20cc/kg, repeated up to a total of 60cc/kg within the first hour, as long as
there are no signs of hepatomegaly, crackles in the lungs, or sonographic evidence
of pulmonary edema.
Q: How would you infuse these fluids in the child who is in septic shock?
IV normal saline “wide open”?
A: IV fluids “wide open” may not deliver fluids fast enough. In order to deliver fluids
faster, for younger children (<2yo), fill a 30-60cc syringe with saline and manually
bolus them by IV push. For older children, use a level 1 infuser.
Q: What quick test is essential to obtain right after the ABC’s?
A: ABC – DEFG = ABC, DON’T EVER FORGET GLUCOSE
272
CH. 2 CONT’D: SEPSIS & SEPTIC SHOCK
Q: What electrolyte abnormality should you be on the lookout for in the

septic pediatric patient and how can you best treat it?
A: Hypocalcemia is commonly seen in critically ill children with sepsis and it is

recommended to treat hypocalcemia even in the absence of clinical manifestations
such as seizures, cardiac arrhythmias. It is treated with calcium gluconate or calcium
chloride if a central line has been placed.
Q: At what point should you be considering vasopressors for your

hypotensive septic pediatric patient?
A: Pressors should be considered if your patient is in fluid-refractory shock defined

as persistent clinical signs of septic shock after receiving 60 cc/kg of crystalloid.
Q: How do you distinguish between warm and cold septic shock in your
patient and which would be more common in children?
A: Warm shock, as seen in most adults in septic shock presents with warm
extremities and flash capillary refill, while cold shock, as seen in most children in
septic shock presents with cool extremities and delayed capillary refill.
Q: Which inotrope would be the best initial choice for your patient if you
determine they are in cold shock? How about if you determine it’s warm
shock instead?
A: Epinephrine would be best if you determine its cold shock while norepinephrine
is preferable for warm shock.
273
CH. 2 CONT’D: SEPSIS & SEPTIC SHOCK
Q: As you are resuscitating your critically ill septic child, what markers of
a successful resuscitation would you be looking for?
A:
•• Capillary refill < 2 sec
•• Normal blood pressure
•• Normal pulses with no differential between central and peripheral pulses
•• Warm extremities
•• Urine output > 1 ml/kg/hr
•• Normal mental status
•• Normal lactate
Q: If neither fluids nor pressors are successful at improving the

hemodynamic status of your patient, what other treatment could you try?
A: Up to 25% of kids with sepsis have adrenal insufficiency either from prior
steroid use, from the cause of sepsis itself or primary adrenal insufficiency.
Adrenal insufficiency in this setting may lead to fluid and pressor refractory shock.
Treatment is hydrocortisone 2mg/kg IV.
274
CHAPTER 3: PAIN MANAGEMENT

Q: You have ordered appropriate analgesia for your pediatric patient,
what are some non-pharmacologic methods to reduce pain?
A: Be creative, use distraction techniques with music, toys, cell phone videos,
or books. You can also use physical elements such as heat, cold and proper
positioning. You can try having a child breast feed if age-appropriate, or giving
oral sucrose to children <6 months. Also remember to get your interprofessional
team on board -- if you have Child Life Specialists, call them, too!
Q: In a child who is still experiencing pain despite appropriate dosages

of Ibuprofen 10 mg/kg and Acetaminophen 15 mg/kg, what could be
your next option orally? IV? to maintain analgesia for hours?
A: A good oral option would be morphine oral suspension at a dose of 0.2 – 0.5
mg/kg PO (max 15 mg) q4-6h. IV morphine is dosed at 0.1 mg/kg IV push and
titrated to effect.
Q: Why should Codeine be avoided in kids?
A: Although long thought of as the preference for managing pain in children,

codeine is a pro-drug that gets converted into morphine. Some people are ultra-
rapid metabolizers of codeine, and receive a huge surge of morphine systemically
along with its adverse effects.
Q: Your pediatric patient is in a lot of pain and you are having trouble
starting an IV. What you would do next?
A: This is a great time to use intranasal fentanyl. The dose of IN fentanyl is

1-1.5mcg/kg to a max of 100mcg. It acts fast within 3 minutes. Use only a volume
of 1.5ml per nare, use both nares if needed. A general rule of thumb is to use
twice the IV dose. Always remember you can use naloxone IN in the event of
respiratory depression.
275
CHAPTER 4: PEDIATRIC HEAD INJURY

Q: In assessing a child with head injury, what are the 6 criteria from the
PECARN study that should be a part of your assessment?
A: 1. Altered mental status

2. Non-frontal scalp hematoma
3. Loss of consciousness for at least 5 seconds
4. Severe mechanism of injury
5. Palpable skull fracture
6. Not acting normally according to the parent
Q: If the child’s history included either isolated vomiting would that

necessitate a CT head to rule out traumatic brain injury?
A: Isolated vomiting should not automatically lead to CT as it is not predictive of

traumatic brain injury. Persistent vomiting associated with other signs of increased
ICP, in contrast, has been shown to have a positive predictive value for traumatic
brain injury.
Q: If you are suspecting a basilar skull fracture, what signs might you be
expecting to find in your pediatric patient?
A: Such signs might include hemotympanum, periorbital ecchymosis (raccoon eyes),

mastoid bone ecchymosis (battle’s sign) or a cerebrospinal fluid leak from the nose
or ears (otorrhoea/rhinorrhoea).
Q: If you are sending your patient with mild or moderate head injury
home is it necessary for their parents to wake them up every 2 hours to
ensure they are acting appropriately?
A: No; however, if overnight includes the first 6 hours after injury it would be
reasonable to wake them up once to ensure they are acting appropriately.
276
CHAPTER 5: PROCEDURAL SEDATION

Q: Why are pediatric patients at higher risk for airway obstruction than
adults?
A: Pediatric patients are at a higher risk of airway obstruction due to anatomical

factors such as large occiput and tongue, and narrower, more pliant airways.
Q: What is the anxiolytic of choice for facilitating a CT scan in a child?
A: For non-painful procedures, distraction should be attempted before medications

are administered. Some departments are equipped with visual equipment that can
distract children in the radiology department.
If distraction techniques are ineffective, IN midazolam is recommended as first
line therapy for sedation. If IN midazolam is not available, oral midazolam is
recommended.
•• Intranasal dose: 0.3mg/kg (max 10mg); time of onset: 7-10min
•• Oral dosing: 0.7mg/kg (max 20mg); time of onset: 15-20min
Before administering midazolam, consider the recovery time and that it may
cloud your physical and neurological assessments of the patient. Perform a good
neurological exam before the sedation!
Q: After an uncomplicated procedural sedation for a distal radius

reduction, how long should you monitor a patient for?
A: Length of observation time depends on agents used and on patient metabolism.
Rough guide to discharge when:

•• Patient is back to developmentally appropriate motor, cognitive and social
function (ex: walk by self, speaking to parents)
•• Patient can tolerate a PO fluid challenge
•• Reliable monitoring plan at home prior to discharge
•• Family comfortable with plan
277
CHAPTER 6: PEDIATRIC ORTHOPEDIC INJURIES

Q: What are the criteria for the Ottawa Knee Rules?
A:
1. Age >55 (omitted in pediatrics
2. Pain at the fibular head
3. Isolated patellar tenderness
4. Inability to flex the knee to 90 degrees
5. Inability to walk four weight-bearing steps both immediately & in the ED
Q: If you suspect an ACL tear, which two fractures should you look out
for on the X-ray?
A: A Segond Avulsion Fracture or Tibial Plateau Fracture
Q: What commonly missed fracture should you consider ruling out in a

limping child?
A: A Toddler’s Fracture
Q: What physical maneuvers should raise your suspicion of this

fracture?
A: Pain with calf rotation or ankle dorsiflexion.
278
CH. 6 CONT’D: ORTHOPEDIC INJURIES

Q: What pediatric age are the Ottawa ankle rules validated for?
A: The Ottawa Ankle rule has been shown to have a high sensitivity for ankle and
mid-foot fractures in children older than five years old.
Q: Which method of immobilization is most appropriate for a 7 year old

who sustains a buckle fracture of the distal radius?
A: Buckle fractures of the distal radius heal well in a removable splint, and studies
show that patients prefer this over a cast. One randomized control trial showed
better physical function, less difficulty with activities, the ability to return to sports
sooner, and pain scores that were either not significantly different when compared
to a short arm cast, or less than with casting.
Q: When examining an x-ray showing a pediatric distal radius fracture,

what degrees of angulation are acceptable by age?
A: Acceptable degrees of angulation depend on the age of the child:

•• <5 years old: up to 30 degrees
•• 5-10 years old: up to 20 degrees
•• 10-12 years old: up to 15 degrees
Q: What are the elements of the Kocher criteria for septic arthritis?
A: Kocher Criteria is a tool to help risk stratify patients suspected of having septic
arthirits. If all four criteria are met, the probability of septic arthritis is 99.6%.
The Kocher Criteria include:

•• Non-weight-bearing on the affected side
•• ESR >40 mm/hr
•• Fever 
•• WBC >12,000
279
CHAPTER 8: ABDOMINAL PAIN & APPENDICITIS

Q: What are the top 5 most common diagnoses that present with the chief
compliant of abdominal pain in children?
A: Gastroenteritis; respiratory tract infection (including otitis media, pharyngitis, and

pneumonia); UTI; constipation; appendicitis
Q: If you administer pain medications to a child with suspected

appendicitis, will it mask your physical exam?
A: No. The myth has long been dispelled that providing analgesia can mask physical
exam findings leading to misdiagnosis in appendicitis.
Q: What is the value of a WBC in ruling in/out appendicitis?
A: There is no laboratory marker that can be used in isolation to definitively rule in or

rule out appendicitis.
A WBC is of limited utility in diagnosing the cause of pediatric abdominal pain. The
likelihood ratios associated with the presence or absence of leukocytosis are not
sufficient to either rule in or rule out appendicitis. Children with gastroenteritis may
have a high WBC with a left shift, while as many as 40% of those with appendicitis
may have no leukocytosis. Nonetheless, a normal WBC does make the diagnosis less
likely.
Q: If you are worried about a patient that may have appendicitis but the
ultrasound report was inconclusive, what should your next step be?
A: If you have a high clinical suspicion, consultation with a pediatric surgeon or

proceeding with a low dose CT would be the next step. If you have a low to moderate
clinical suspicion, consider having the patient return in 12-24hrs for a repeat
ultrasound, as the sensitivity of ultrasound increases with time from symptom onset.
280
CHAPTER 10: GASTROENTERITIS, CONSTIPATION

& OBSTRUCTION
Q: If you have a pediatric patient in whom you suspect a diagnosis of
gastroenteritis, what are some key diagnoses that should cross your
mind to at least consider prior to making the diagnosis?
A:
•• Intracranial Mass
•• Meningitis
•• Intussusception
•• Diabetic Ketoacidosis
•• Cholinergic Syndrome
•• Pneumonia
•• Myocarditis
•• Appendicitis
•• Urinary Tract Infection
Q: If you are trying to determine if this child is dehydrated, what are the 4
most useful clinical exam findings that you should look for?
A: From the Gorelick Score, 2 or more of the following suggests > 5% dehydration:
•• Capillary Refill > 2 seconds
•• Absent tears
•• Dry mucous membranes
•• Ill general appearance
Q: If on history you hear of ingestion of an undercooked hamburger and

have at least a suspicion of Hemolytic Uremic Syndrome what is the
classic triad of lab findings you should expect to see and what would you
look for on exam?
A: The classic triad of HUS is microangiopathic hemolytic anemia, thrombocytopenia,

and renal insufficiency. Clinical features that should raise suspicion for HUS include
bloody stool, abdominal pain, lethargy, low-grade fever, paleness and tachycardia,
petechia, periorbital edema (especially upon waking) and tea colored urine.
281
CHAPTER 11: DIABETIC KETOACIDOSIS

Q: What are the initial management steps in pediatric cerebral edema
associated with DKA?
A:
•• Elevate the head of the bed to 30 degrees
•• Mannitol 0.5-1g/kg over 20 minutes or
•• 3% Hypertonic Saline 5-10cc/kg IV over 30 minutes
Q: What is the only situation you would consider giving a child with DKA
fluid boluses?
A: Fluid boluses are only indicated in pediatric DKA patients who are in
decompensated shock. If a child has a blood pressure below 70 + (2 x Age), judicious
fluids should be given until the pressure corrects above this range.
Q: What is the timing, dose and rate of initial IV insulin treatment for the
child in moderate or severe DKA?
A: Initial insulin infusion should be between 0.05-0.1 unit/kg/hour. There is no role

for insulin boluses in pediatric patients with DKA due to an association with cerebral
edema.
Insulin should be administered after 1-2 hours of intravenous fluids.
Q: How is the severity of DKA categorized?
A: The severity of DKA is classified based on the degree of acidosis and the HCO3
level.
282
CH. 11 CONT’D: DIABETIC KETOACIDOSIS

Q: Which blood tests are most useful to monitor treatment in a child in
DKA?
A: Serum ketones or a decreasing anion gap are both useful in monitoring ketosis
and treatment.
Q: How does the management of DKA differ between adult and pediatric
patients?
A:
1. IV fluids – While adult DKA guidelines recommend multiple fluid boluses in the
first 2 hours of care, fluid boluses are only indicated in pediatric patients who
are in decompensated shock. Judicious use of IV fluids is encouraged with twice
maintenance being the upper limit of administration.
2. Potassium management – Adult DKA patients have strict potassium cut-offs
that guide insulin administration, but potassium management in pediatric DKA
is less stringent. This is likely a result of pediatric patients being less prone to
arrhythmias with hypokalemia.
3. Sodium bicarbonate – While sodium bicarbonate is recommended in adult
DKA with a pH < 7.1, its use in pediatric DKA is limited to patients with cardio-
vascular collapse.
283
CHAPTER 12: PEDIATRIC BRONCHIOLITIS

Q: Is it normal for a 6 month old patient to breathe 50 breaths per minute?
A: No! The upper limits of normal for respiratory rate in children are:
•• Term Neonate – 50 breaths/min
•• 6 month old – 40 breaths/min
•• 12 month old – 30 breaths/min
Q: If clinically you suspect bronchiolitis in your patient, do they require a

chest x-ray to confirm the diagnosis?
A: Chest x-rays are not recommended as a routine test in children suspected of

bronchiolitis according to The American Association of Pediatricians guidelines.
Q: Is salbutamol (Albutarol or Ventolin) indicated in children with

suspected bronchiolitis?
A: A trial of salbutamol is reasonable if there is a strong family history of asthma,

atopy or in the patient who has had multiple wheezing episodes.
Q: How about nebulized epinephrine for the child suspected of

bronchiolitis?
A: There isn’t great evidence for the use of nebulized epinephrine in bronchiolitis;
however, a Cochrane Review did find some benefit in those patients who were
admitted to hospital so nebulized epinephrine may be considered in patients in
whom you suspect admission will be the likely disposition.
Q: Are steroids of any benefit in treating bronchiolitis?
A: Corticosteroids alone are not recommended in bronchiolitis, however there

is some evidence to suggest that the combination of steroids and nebulized
epinephrine may be of some benefit.
284
CH. 12 CONT’D: PEDIATRIC BRONCHIOLITIS

Q: How about nebulized hypertonic saline for bronchiolitis?
A: The evidence for hypertonic saline is equivocal but it is reasonable to try in kids
likely requiring admission.
Q: What are the risk factors for apnea in bronchiolitis?
A: The overall incidence of apnea with bronchiolitis is 2.7%.
Risk factors for apnea with bronchiolitis include:

•• Age < 2 months
•• Small for gestational age (weight < 2.3kg)
•• Previous episode of apnea
•• Oxygen saturation < 90%
Q: What are the published criteria for admission in bronchiolitis?
A: From the Canadian Pediatric Society 2014 guidelines:

•• Signs of severe respiratory distress (ie. indrawing, grunting, or RR>70)
•• Supplemental O2 required to keep saturations >90%
•• Dehydration or history of poor fluid intake
•• Cyanosis or history of apnea
•• Family unable to cope
•• Infant at high risk for severe disease (born at < 35 weeks gestation, <3
months old, hemodynamically significant cardiopulmonary disease,
immunodeficiency)
285
CHAPTER 13 & 15: PEDIATRIC ASTHMA & CROUP

Q: In evaluating an asthmatic child, what aspects of their past history
will you solicit in order to gauge the severity of their asthma?
A:
•• Previous life-threatening exacerbations
•• Admissions to ICU
•• Intubation
•• Deterioration while already on systemic steroids
•• Using more than 2 canisters of short acting B-agonist per month
•• Cardiopulmonary and psychiatric comorbidities
Q: What are the features on history or physical exam that you might
elicit that should make you consider ordering an x-ray for your pediatric
patient with a clinical asthma exacerbation?
A:
•• Focal chest findings (unilateral wheezing, or crackles)
•• Fever
•• Extreme distress
•• Subcutaneous emphysema
•• History of choking
Q: How long do corticosteroids given to a child with an asthma

exacerbation take to show a clinical benefit?
A: Corticoteroids typically take at least 2 hours to work and should therefore be

given early in the ED presentation.
Q: If you elect to treat your patient with the severe exacerbation with
magnesium, why would it be important to infuse it slowly?
A: Magnesium should be administered over at least 20 minutes to avoid the most

common side effect of hypotension.
286
CHAPTER 16: PEDIATRIC SYNCOPE

Q: What are features you might elicit on history and physical exam that
should prompt a further evaluation to rule out a cardiac or neurological
cause of the syncope?
A:
•• Syncope during physical exertion
•• Family history of sudden cardiac death or deafness
•• Chest pain, palpitations or dyspnea
•• History of structural heart disease
•• Abnormal cardiac exam
•• Focal neurological findings
Q: In a pediatric patient in whom you auscultate an outflow murmur that

increases with valsalva or standing, what pathology must be considered?
A: An outflow murmur that increases with valsalva or standing in a child presenting

with syncope is hypertrophic cardiomyopathy until proven otherwise.
Q: What are the key features of this ECG and what is the disease are they
typical of?
287
CH. 16 CONT’D: PEDIATRIC SYNCOPE

A: This ECG is suggestive of hypertrophic cardiomyopathy (HCM) courtesy of the
Life in the Fast Lane blog. ECG findings of HCM include:
•• Increased QRS complex voltage (‘Dagger Q waves’)
•• ST-segment and T-wave signs of LV hypertrophy
•• Q-waves in leads II, III, aVF, V5, V6
Q: What pathology is this ECG

suggestive of?
A:
This ECG is suggestive of arrhythmogenic right ventricular cardiomyopathy (ARVC).
Key ECG findings in ARVC include:

•• Inverted T waves in right precordial leads (V1, V2, V3)
•• QRS in Lead 1 > 110 msec
•• Epsilon waves (low amplitude notches after QRS and before T wave) in the right
precordial leads (V1- V3)
Q: This ECG is suggestive of what cardiac disease that can cause syncope
and sudden death?
A: Courtesy of Life in the Fast Lane blog
288
CH. 16 CONT’D: PEDIATRIC SYNCOPE

A: This ECG is suggestive of Wolf Parkinson White (WPW) syndrome, which typically
includes the following elements:
•• Short PR interval of less than 3 small squares (120 ms),
•• Slurred upstroke to the QRS indicating pre-excitation (delta wave)
•• Broad QRS
•• Secondary ST and T wave changes
Q: What is the typical story of a patient who suffers a syncopal episode

as a result of Long QT Syndrome?
A: The history of pediatric patients who present to the ED with syncope related
to Long QT Syndrome typically involves exertion such as swimming, or emotional
distress. These patients can also suffer an abrupt onset of syncope due to fright or
awakening by a loud noise, such as an alarm clock.
Q: What QTc length in the ECG of a pediatric patient would warrant

referral to a cardiac electrophysiologist?
A: In children a QTc interval >450 is considered high risk in contrast to adults

where a QTc>500 is considered high risk.
289
CHAPTER 17: PEDIATRIC SEIZURES

Q: If parents come to your ED with a child with a history of shaking, what
features might suggest you are dealing with a true seizure?
A:
•• Post-ictal phase (rapid/immediate return to normal activity is unlikely to follow
a true seizure)
•• Lateral tongue biting
•• Flickering eye lids
•• Blank stare or deviated eyes
•• Lip smacking
•• Increased heart rate and blood pressure during the event
Q: How do you differentiate a seizure from a breath holding spell?
A: The temporary decrease in cerebral oxygenation in a breath holding spell can

cause very brief seizure activity making the diagnoses difficult to distinguish.
However, a breath holding spell typically has a Clear trigger (emotional distress or
pain) and rapid and complete recovery (no post ictal phase).
Q: What features of a witnessed seizure might you elicit that would tend
to favour the diagnosis of pseudoseizure?
A:
•• Adolescent population
•• Movements such as side to side head motion, back arching, asynchronous
movement (ie bicycling)
•• Preserved level of consciousness
290
CH. 17 CONT’D: PEDIATRIC SEIZURES

Q: In evaluating a febrile seizure in a pediatric patient, what features
would suggest a complex rather than simple febrile seizure?
A:
Q: If the parents of your patient with the febrile seizure tell you that
this is his third day of fever would this be more or less worrisome for an
underlying serious bacterial infection?
A: Simple febrile seizures tend to occur within the first 24 hours of a febrile illness.
If the seizure occurs > 24 hrs after the onset of fever the index of suspicion for
more severe bacterial illness should be heightened.
Q: What workup does a child suffering a simple febrile seizure require?
A: If your history suggests that the seizure is a simple febrile seizure, then no
specific workup is required for the seizure, other than investigating the fever as
you would in any other febrile child.
Q: Does every complex febrile seizure patient require a CT Head? If not,

then which patients with febrile seizures do require a CT Head?
A: Indications for neuroimaging in the ED in the child with a febrile seizure:

•• Suspicion of non-accidental injury
•• Signs of increased ICP
•• Patient who do not return to neurologic baseline
•• Underlying known CNS disorder (eg VP shunt)
291

Q: How would you counsel the parents of this febrile seizure patient
regarding the risk of recurrence and the risk of epilepsy for their child?
A: Risk of recurrence is approximately 33% overall with a higher risk in children

•• <18 months of age
•• Temperature < 40.0°C at first convulsion
•• <1hr between onset of fever and first seizure
•• Family history of febrile seizures
If they have all 4 of the factors, their risk of recurrence is 70%. If they don’t meet
any criteria, their risk falls to 20%.
The risk of epilepsy is approximately 2% after a simple febrile seizure and 5 % after
a complex febrile seizure (compared to 1% in the general population).
Q: If a child presents to your ED with a non-febrile seizure, should you

automatically order a head CT head? If not, what are some features on
history that might push you to do so?
A: Neuroimaging is generally not necessary in the ED in a child after a non-febrile

seizure who returns to neurologic baseline. Some high-risk criteria for finding a
culprit lesion on a CT scan of the head are:
•• Focal seizure or persistent seizure activity
•• Focal neurologic deficit
•• VP shunt
•• Neurocutaneous disorder suggested on skin exam
•• Signs of elevated increased ICP
•• History of trauma
•• Travel to an area endemic for neurocysticercosis
•• Immunocompromised state
•• Hypercoagulable state (eg sickle cell disease) or bleeding disorder
292

Q: If an infant presents with a non-febrile seizure and is found to be
hyponatremic, what is the likely cause of their seizure?
A: Overdilution of infant formula, either from attempts at cost savings or error,

would be the most likely cause.
Q: If a child arrives to your department in status epilepticus with no IV

access, what are 4 alternate routes you could consider for medication
deliver?
A: Intramuscular (midazolam), intranasal (midazolam), buccal (midazolam,

lorazepam) or rectal (lorazepam, diazepam).
Q: If your status epilepticus patient is still seizing after 2 or 3 rounds of

an appropriately dosed benzodiazepine, what medication would you next
move to?
A: Fosphenytoin is the recommended second line medication for status

epilepticus. If fosphenytoin is not available in your department then phenytoin can
be substituted.
Q: If you have given 3 rounds of benzos to your seizing patient and a load
of phenytoin or fosphenytoin but they are still seizing, what is your next
step?
A: The next step would be a continuous infusion or either midazolam,

pentobarbital, propofol or thiopental.
293

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THE MAGAZINE SERIES FOR ENHANCED EM LEARNING

Vol. 2: Pediatric Emergencies

Vol. 2: Pediatric Emergencies

Emergency Medicine Cases by Medicine Cases is copyrighted as “All Rights

CHAPTER WRITERS PODCAST SUMMARY EDITORS

PODCAST GUEST EXPERTS

University of Toronto, Faculty of Medicine

EM Cases is a venture of the Schwartz/

Anton Helman, MD, CCFP(EM), FCFP

Thanks to TREKK for its partnership in recruiting

Social media technologies are game-changers in health professions education.

As a blogger, however, I am keenly aware that blogs and podcasts generally

From a pedagogical and instructional design standpoint, this innovative

Your friend and fan,

Here’s a little description

Tools Expert Expert Opinion:

References you do? Comments

Chapter 1: Fever Without a Source Page 4

Chapter 2: Sepsis and Septic Shock Page 22

Chapter 3: Pain Management Page 35

Chapter 4: Head Injury Page 53

Chapter 5: Pediatric Procedural Sedation Page 68

Chapter 6: Orthopedic Injuries Page 82

Chapter 7: POCUS Nerve Blocks Page 106

Chapter 8: Abdominal Pain and Appendicitis Page 117

Chapter 9: POCUS Appendicitis and Intussusception Page 132

Chapter 10: Gastroenteritis, Constipation and Obstruction Page 143

Chapter 11: Diabetic Ketoacidosis Page 168

Chapter 12: Bronchiolitis Page 183

Chapter 13: Asthma Page 197

Chapter 14: Lung POCUS Page 212

Chapter 15: Croup Page 221

Chapter 16: Pediatric Syncope Page 230

Chapter 17: Pediatric Seizures Page 250

Rapid Review Questions Page 269

A small but significant number of this 20% without an identifiable source of

Q: Does this child require a rectal temperature measurement?

A: As rectal temperatures are the most accurate estimation of core body

In terms of predicting bacteremia, the precise height of the Video:

Q: This child has a rectal temperature of 39°C.

A parent’s assessment of A: While this temperature is not inherently

Expert Opinion: A: Studies show that ibuprofen is superior at treating

Case continued: On exam of this 12-month-old female, she appears tired

Q: What is the normal change in heart rate and respiratory rate in

A: Respiratory rate: Heart rate:

For every degree of fever above 38°C

So, in our 12-month-old girl:

Normal Pediatric Vital Signs by Age

Heart Rate 100 to 160 bpm 70 to 120 bpm 60 to 100 bpm

0 to 6 months 90 to 110 systolic / 110 to 135 systolic/

Tympanic Temperature 35.8°C to 38°C (96.4°F to 100.4°F)

Oral Temperature 35.5°C to 37.5°C (95.9°F to 99.5°F)

Axillary Temperature 34.7°C to 37.3°C (94.5°F to 99.1°F)

Case resolution: The child is observed in the ED and is treated with

Q: This child has no source of infection that is readily

A: Fever without a source: There is no identifiable source of fever after a

Fever of unknown origin: At least two to three weeks of fever without an

Q: For children who present to the ED with fever without a

A: A small proportion of these infants and young children will have