Trauma

Concussions

Concussions and closed head injuries are incredibly common in the Pediatric Emergency Department and in general Emergency Department, especially as we head into fall contact sports season. In this episode, featuring Brielle Stanton, MD, a Pediatric Emergency Medicine fellow from The UPMC Children’s Hospital of Pittsburgh, you will earn how to differentiate clinically important traumatic brain injuries from milder trauma – specifically when to get a CT, and how to diagnose and manage concussions.

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Resources

MD Calc: Pediatric Head Injury/Trauma Algorithm

MD Calc: Glasgow Coma Scale

Healthy Children: Concussions: What parents Need to Know

CDC: Heads Up

References

Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70. doi: 10.1016/S0140-6736(09)61558-0. Epub 2009 Sep 14. Erratum in: Lancet. 2014 Jan 25;383(9914):308. PMID: 19758692.

Schonfeld D, Bressan S, Da Dalt L, Henien MN, Winnett JA, Nigrovic LE. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Arch Dis Child. 2014 May;99(5):427-31. doi: 10.1136/archdischild-2013-305004. Epub 2014 Jan 15. PMID: 24431418.

Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, Turner M, Benzel EC, Suskauer SJ, Giza CC, Joseph M, Broomand C, Weissman B, Gordon W, Wright DW, Moser RS, McAvoy K, Ewing-Cobbs L, Duhaime AC, Putukian M, Holshouser B, Paulk D, Wade SL, Herring SA, Halstead M, Keenan HT, Choe M, Christian CW, Guskiewicz K, Raksin PB, Gregory A, Mucha A, Taylor HG, Callahan JM, DeWitt J, Collins MW, Kirkwood MW, Ragheb J, Ellenbogen RG, Spinks TJ, Ganiats TG, Sabelhaus LJ, Altenhofen K, Hoffman R, Getchius T, Gronseth G, Donnell Z, O’Connor RE, Timmons SD. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatr. 2018 Nov 1;172(11):e182853. doi: 10.1001/jamapediatrics.2018.2853. Epub 2018 Nov 5. Erratum in: JAMA Pediatr. 2018 Nov 1;172(11):1104. PMID: 30193284; PMCID: PMC7006878.

Zuckerbraun NS, Atabaki S, Collins MW, Thomas D, Gioia GA. Use of modified acute concussion evaluation tools in the emergency department. Pediatrics. 2014 Apr;133(4):635-42. doi: 10.1542/peds.2013-2600. Epub 2014 Mar 10. PMID: 24616361.

Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, Howe NL, Ronckers CM, Rajaraman P, Sir Craft AW, Parker L, Berrington de González A. 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. doi: 10.1016/S0140-6736(12)60815-0. Epub 2012 Jun 7. PMID: 22681860; PMCID: PMC3418594.

Miglioretti DL, Johnson E, Williams A, et al. The use of computed tomography in pediatrics and the associated radiation exposure and estimated cancer risk. JAMA Pediatr. 2013;167(8):700-707. doi:10.1001/jamapediatrics.2013.311

Mannix R, Bazarian JJ. Managing Pediatric Concussion in the Emergency Department. Ann Emerg Med. 2020 Jun;75(6):762-766. doi: 10.1016/j.annemergmed.2019.12.025. Epub 2020 Feb 17. PMID: 32081385.

Zemek R, Barrowman N, Freedman SB, Gravel J, Gagnon I, McGahern C, Aglipay M, Sangha G, Boutis K, Beer D, Craig W, Burns E, Farion KJ, Mikrogianakis A, Barlow K, Dubrovsky AS, Meeuwisse W, Gioia G, Meehan WP 3rd, Beauchamp MH, Kamil Y, Grool AM, Hoshizaki B, Anderson P, Brooks BL, Yeates KO, Vassilyadi M, Klassen T, Keightley M, Richer L, DeMatteo C, Osmond MH; Pediatric Emergency Research Canada (PERC) Concussion Team. Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED. JAMA. 2016 Mar 8;315(10):1014-25. doi: 10.1001/jama.2016.1203. Erratum in: JAMA. 2016 Jun 21;315(23):2624. PMID: 26954410.

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Orthopedics

Shoulder Dislocations

What’s the best maneuver for reducing a dislocated shoulder? My guess is as good as yours. There are multiple maneuvers that work – and work well for anterior (AKA anterior-inferior) dislocations. This episode reviews how to manage shoulder dislocations in the Pediatric population.

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References

Fox, Shoulder Dislocations. Pediatric EM Morsels. July 31, 2015. https://pedemmorsels.com/shoulder-dislocation/. Accessed June 23, 2021.

Zacchilli MA Owens BD. Epidemiology of shoulder dislocations presenting to emergency departments in the United States. J Bone Joint Surg Am. 2010 Mar;92(3):542-9. PMID: 20194311.

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Tags shoulder dislocation

Orthopedics

Finger Dislocations

It is much more common for children to break a finger than dislocate one. Why? Those darn growth plates. Nevertheless reducing a dislocated digit is one of the most common emergency procedures around and can generally be performed without much difficulty. However there are some situations where you shouldn’t just yank in the digit. Learn about these situations and more in this episode.

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References

Borchers et al. Common Finger Fractures and Dislocations. Am Fam Physician. 2012 Apr 15;85(8):805-810.

Ahn and Blomberg. Phalanx Dislocations. Ortho Bullets. https://www.orthobullets.com/hand/6038/phalanx-dislocations. Updated 5/17/21. Accessed June 23, 2021.

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Tags finger dislocation

Orthopedics

Patella Dislocations

Reducing a dislocated patella is super satisfying – both for the clinician and the patient. This episode reviews management of this common orthopedic concern so that you can perform a reduction maneuver without needing to call Orthopedics.

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References

Fithian DC,Paxton EW,Stone ML,Silva P,Davis DK,Elias DA,White LM, Epidemiology and natural history of acute patellar dislocation. The American journal of sports medicine. 2004 Jul-Aug; [PubMed PMID: 15262631]

Jain NP,Khan N,Fithian DC, A treatment algorithm for primary patellar dislocations. Sports health. 2011 Mar; [PubMed PMID: 23016004]

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Tags patella dislocation

Orthopedics

Nursemaid’s Elbow

Never has there been a more anachronistic name for such a common malady. Hailing from the time when the wealthy had female domestic workers who cared for children within their large household, this outmoded eponym describes a common orthopedic condition that impacts young children. I’ll cast my vote for calling it “pulled elbow” like they do in Australia – because it describes when happens when the radial head subluxes from its usual position nestled in the annular ligament. This episode discusses the diagnosis and management of this can’t miss condition, that I suspect our residents and students aren’t seeing as much as they should.

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References

Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics. 1998 Jul;102(1):e10. doi: 10.1542/peds.102.1.e10. PMID: 9651462.

Nardi NM, Schaefer TJ. Nursemaid Elbow. [Updated 2020 Nov 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-.

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Tags nursemaid's elbow, pulled elbow

Adolescent

Adolescent sexual and reproductive health in the ED

Post author By bradsobo
Post date June 2, 2021
No Comments on Adolescent sexual and reproductive health in the ED

This episode features three members of the Pediatric Emergency Care Applied Research Network (PECARN) Adolescent Sexual Health Working Group. PECARN is a network that performs multicenter research related to the emergency care of children. The Adolescent Sexual Health Working Group is focused on researching topics of interest around sexual and reproductive health in the ED. I recently had the pleasure of interviewing three of the study authors and recorded our conversations, then created a podcast episode that hit on some of the highlights of their incredible work. James Gray also helped me put a blog post together that delves into some of the topics in a bit more in depth fashion.

This episode features the contributions of:

Melissa Miller, MD
Associate Professor of Pediatrics
Division of Emergency Medicine
Children’s Mercy Hospital Kansas City

Lauren Chernick, MD, MSc
Assistant Professor of Pediatrics in Emergency Medicine
Columbia University Medical Center

Erin Hoehn, MD
Assistant Professor of Pediatrics
Division of Emergency Medicine
Children’s Hospital of Pittsburgh

Check out the companion blog post at PEMBlog.com

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Key Article

Miller MK, Chernick LS, Goyal MK, et al. A Research Agenda for Emergency Medicine-based Adolescent Sexual and Reproductive Health. Acad Emerg Med. 2019;26(12):1357-1368. doi:10.1111/acem.13809

References

Brown J, Fleming R, Aristzabel J, Gishta R. Does pelvic exam in the emergency department add useful information?. West J Emerg Med. 2011;12(2):208-212.

Farrukh S, Sivitz AB, Onogul B, Patel K, Tejani C. The Additive Value of Pelvic Examinations to History in Predicting Sexually Transmitted Infections for Young Female Patients With Suspected Cervicitis or Pelvic Inflammatory Disease. Ann Emerg Med. 2018 Dec;72(6):703-712.e1. doi: 10.1016/j.annemergmed.2018.05.004. Epub 2018 Jul 2. PMID: 30251627.

Linden JA, Grimmnitz B, Hagopian L, Breaud AH, Langlois BK, Nelson KP, Hart LL, Feldman JA, Brown J, Reid M, Desormeau E, Mitchell PM. Is the Pelvic Examination Still Crucial in Patients Presenting to the Emergency Department With Vaginal Bleeding or Abdominal Pain When an Intrauterine Pregnancy Is Identified on Ultrasonography? A Randomized Controlled Trial. Ann Emerg Med. 2017 Dec;70(6):825-834. doi: 10.1016/j.annemergmed.2017.07.487. Epub 2017 Sep 19. PMID: 28935285.

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gastroenterology

Magnet Ingestions

This episode focuses on high-powered magnet ingestions in children and was a collaboration with Elizabeth Curtis – @egcurtismd and Libby Ireson – @LibbyIreson, two Categorical Pediatrics Residents at Cincinnati Children’s who served as producers and guest hosts. These rare earth magnets were briefly removed from the market because children swallowed them and, when two magnets attracted across opposing loops of bowel, they sustained intestinal injury. Legal machinations led to their reappearance on the market.

This episode is equal parts clinical advice and advocacy in action and will help you discuss these potentially dangerous magnets with families and manage a child in case they swallow one.

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References

CPSC Safety Alert (2007) “Ingested Magnets Can Cause Serious Intestinal Injuries” https://www.cpsc.gov/s3fs-public/5221.pdf

AAP (2017) “Dangers of Magnetic Toys.” https://www.healthychildren.org/English/safety-prevention/at-home/Pages/Dangers-of-Magnetic-Toys-and-Fake-Piercings.aspx

Middelberg, L. K., Funk, A. R., Hays, H. L., McKenzie, L. B., Rudolph, B., & Spiller, H. A. (2021). Magnet Injuries in Children: An Analysis of the National Poison Data System From 2008-2019. The Journal of Pediatrics, 0(0). https://doi.org/10.1016/j.jpeds.2021.01.052

Strickland M, Rosenfield D, Fecteau A. Magnetic foreign body injuries: a large pediatric hospital experience. J Pediatr. 2014 Aug;165(2):332-5. doi: 10.1016/j.jpeds.2014.04.002. Epub 2014 May 16. PMID: 24836391.

De Roo AC, Thompson MC, Chounthirath T, Xiang H, Cowles NA, Shmuylovskaya L, Smith GA. Rare-earth magnet ingestion-related injuries among children, 2000-2012. Clin Pediatr (Phila). 2013 Nov;52(11):1006-13. doi: 10.1177/0009922813507129. PMID: 24137035.

Mandhan, P., Alsalihi, M., Mammoo, S., & Ali, M. J. (2014). Troubling toys: rare-earth magnet ingestion in children causing bowel perforations. Case reports in pediatrics, 2014.

Reeves, P. T., Nylund, C. M., Krishnamurthy, J., Noel, R. A., & Abbas, M. I. (2018). Trends of magnet ingestion in children, an ironic attraction. Journal of pediatric gastroenterology and nutrition, 66(5), e116-e121.

Spiller, H. (2019) “The Dangers of Magnet Toys.” Nationwide Children’s Hospital www.nationwidechildrens.org/family-resources-education/700childrens/2019/12/magnet-toys

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Tags high powered magnet ingestions, magnet ingestions

Resuscitation

Drowning

Post author By bradsobo
Post date May 12, 2021
No Comments on Drowning

With the warm weather upon us here in the Northern Hemisphere it will soon be time for the pools to open. This episode is therefore incredibly timely, and focuses on the spectrum of submersion injuries and their management. Learn about drowning physiology, when to admit to the hospital, and how to assess the child who went under water unexpectedly but looks fine from this episode’s special co-host and producer, Joe Finney, MD a PGY-5 Pediatric Emergency Medicine and EMS fellow from Washington University in Saint Louis, MO. You can connect will Joe via email at Josephfinney@wustl.edu.

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References

A65. NICU, PICU AND CHRONIC VENTILATION. American Thoracic Society International Conference Meetings Abstracts American Thoracic Society International Conference Meetings Abstracts, www.atsjournals.org/doi/abs/10.1164/ajrccm-conference.2016.193.1_MeetingAbstracts.A2198.

Zuckerman GB, Gregory PM, Santos-Damiani SM. Predictors of Death and Neurologic Impairment in Pediatric Submersion Injuries: The Pediatric Risk of Mortality Score. Arch Pediatr Adolesc Med. 1998;152(2):134–140. doi:10.1001/archpedi.152.2.134

Watson RS, Cummings P, Quan L, Bratton S, Weiss NS. Cervical spine injuries among submersion victims. J Trauma. 2001 Oct;51(4):658-62. doi: 10.1097/00005373-200110000-00006. PMID: 11586155.

Gonzalez-Luis G, Pons M, Cambra FJ, Martin JM, Palomeque A. Use of the Pediatric Risk of Mortality Score as predictor of death and serious neurologic damage in children after submersion. Pediatr Emerg Care. 2001 Dec;17(6):405-9. doi: 10.1097/00006565-200112000-00002. PMID: 11753182.

Noel S. Zuckerbraun, Richard A. Saladino, Pediatric Drowning: Current Management Strategies for Immediate Care, Clinical Pediatric Emergency Medicine, Volume 6, Issue 1, 2005, Pages 49-56, ISSN 1522-8401, https://doi.org/10.1016/j.cpem.2004.12.001. (https://www.sciencedirect.com/science/article/pii/S1522840104000874)

Szpilman D, Morgan PJ. Management for the Drowning Patient. Chest. 2020 Oct 14:S0012-3692(20)34896-0. doi: 10.1016/j.chest.2020.10.007. Epub ahead of print. PMID: 33065105.

Noonan L, Howrey R, Ginsburg CM. Freshwater submersion injuries in children: a retrospective review of seventy-five hospitalized patients. Pediatrics. 1996 Sep;98(3 Pt 1):368-71. PMID: 8784358.

Quan L, Kinder D. Pediatric submersions: prehospital predictors of outcome. Pediatrics. 1992 Dec;90(6):909-13. PMID: 1437433.

Szpilman D. Near-drowning and drowning classification: a proposal to stratify mortality based on the analysis of 1,831 cases. Chest. 1997 Sep;112(3):660-5. doi: 10.1378/chest.112.3.660. PMID: 9315798.

Best RR, Harris BHL, Walsh JL, Manfield T. Pediatric Drowning: A Standard Operating Procedure to Aid the Prehospital Management of Pediatric Cardiac Arrest Resulting From Submersion. Pediatr Emerg Care. 2020 Mar;36(3):143-146. doi: 10.1097/PEC.0000000000001169. PMID: 28486266.

Davey M, Callinan S, Nertney L. Identifying Risk Factors Associated with Fatal Drowning Accidents in the Paediatric Population: A Review of International Evidence. Cureus. 2019 Nov 19;11(11):e6201. doi: 10.7759/cureus.6201. PMID: 31890403; PMCID: PMC6919957.

Habib DM, Tecklenburg FW, Webb SA, Anas NG, Perkin RM. Prediction of childhood drowning and near-drowning morbidity and mortality. Pediatr Emerg Care. 1996 Aug;12(4):255-8. doi: 10.1097/00006565-199608000-00005. PMID: 8858647.

Son KL, Hwang SK, Choi HJ. Clinical features and prognostic factors in drowning children: a regional experience. Korean J Pediatr. 2016 May;59(5):212-7. doi: 10.3345/kjp.2016.59.5.212. Epub 2016 May 31. PMID: 27279885; PMCID: PMC4897156.

“Almost 800 Kids Drown Each Year; More than Half Are Under Age 5.” Safe Kids Worldwide, 29 June 2016, safekids.org/press-release/almost-800-kids-drown-each-year-more-half-are-under-age-5.

“Drowning Prevention.” Services.aap.org, services.aap.org/en/news-room/campaigns-and-toolkits/drowning-prevention/.

“WISQARS (Web-Based Injury Statistics Query and Reporting System)|Injury Center|CDC.” Centers for Disease Control and Prevention, Centers for Disease Control and Prevention, 1 July 2020, www.cdc.gov/injury/wisqars/.

Idris AH, Berg RA, Bierens J, Bossaert L, Branche CM, Gabrielli A, Graves SA, Handley AJ, Hoelle R, Morley PT, Papa L, Pepe PE, Quan L, Szpilman D, Wigginton JG, Modell JH. Recommended guidelines for uniform reporting of data from drowning: the “Utstein style.”Circulation. 2003; 108:2565–2574. doi: 10.1161/01.CIR.0000099581.70012.68

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Tags drowning, submersion injury

Toxicology

Toxicology Season 2 Episode 3: Nicotine

Post author By bradsobo
Post date March 16, 2021
No Comments on Toxicology Season 2 Episode 3: Nicotine

This is Season 2 of the Toxicology podcast series that Seattle Childrens’ Toxicologist Suzan Mazor, MD and I put together. This three episode season turns its focus to drugs of abuse – continuing with this episode on nicotine toxicity – the final episode of this #ToxTuesdays season.

I am now proud to offer CME through Cincinnati Children’s. To claim visit Cincinnati Children’s Online Courses and search ‘PEM Currents’.

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References

American College of Medical Toxicology: Nicotine

CDC: Outbreak of Lung Injury Associated with the Use of E-Cigarette, or Vaping, Products

Yale medicine – E-cigarette or Vaping Product Use-Associated Lung Injury (EVALI). YaleMedicine.org

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Toxicology

Toxicology Season 2 Episode 2: Marijuana

Post author By bradsobo
Post date March 9, 2021
No Comments on Toxicology Season 2 Episode 2: Marijuana

This is Season 2 of the Toxicology podcast series that Seattle Childrens’ Toxicologist Suzan Mazor, MD and I put together. It is a joint effort so to speak. This three episode season turns its focus to drugs of abuse – continuing with this episode on marijuana toxicity. So, let’s weed out the bad information, hash out the details, and learn about cannabinoid toxicity in this #ToxTuesdays episode.

I am now proud to offer CME through Cincinnati Children’s. To claim visit Cincinnati Children’s Online Courses and search ‘PEM Currents’.

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