Acute Management in Pediatric Congestive Heart Failure

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Author: Alfred Morrobel, M.D
Universidad Iberoamericana

Epidemiology
Congestive heart failure (CHF) in children is diverse due to the myriad underlying etiologies that can occur from birth to adolescence. In the United States, CHF is estimated to affect 12,000 to 35,000 children below the age of 19 years and there are approximately 11,000 to 15,000 heart failure-related hospitalizations in children per year.[1]

Did You Know? Broselow Pediatric Emergency Tape

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Author: Jenna Erickson, MD
Phoenix Children's Hospital/Maricopa Medical Center
Originally Published: Modern Resident August/September 2015

In a pediatric trauma, one of the initial treatment steps is determination of a child’s “color.” This is referencing the Broselow Pediatric Emergency Tape, an old but widely accepted method of estimating a child’s weight based on length. Pediatric drug dosing is based on weight, therefore a fast, efficient way to calculate dosing is essential to reduce medical error and optimize patient outcomes. The Broselow Tape is a color-coded tape measurer consisting of nine color zones that group together pediatric medication doses and equipment sizes. When a child first arrives in a trauma bay he is measured with the tape from crown to heel. The color that is reached by the child’s heel indicates a weight estimate; this color is then used for a quick reference sheet of pre-calculated medication doses, voltages and equipment sizes. Resuscitation carts with color-coded drawers further simplify the process of selecting the correct supplies for pediatric patients, thus expediting treatment and minimizing error.

Maybe Grandma Was Right: Dilute Apple Juice for Pediatric Oral Rehydration

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Author: Ashley Grigsby, DO PGY-3
Indiana University
Emergency Medicine/Pediatrics Residency

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Acute gastroenteritis is a common diagnosis for pediatric patients in emergency departments across the country. Although the cause is usually viral, successful treatment consists of adequate fluid hydration and supportive care through the course of the child’s illness.[1] The ability to keep a child hydrated through the illness is a major contributor to the successful outpatient management of these patients. There are oral rehydration solutions (ORS) available that have been recommended due to their ideal electrolyte concentrations, however, some children refuse to drink them because of the taste.[1] High sugar drinks, such as sports drinks, have also been thought to induce osmotic diarrhea and therefore have not been previously recommended for gastroenteritis.[1] Throughout my short career, I’ve had many parents tell me they give watered-down juice because “that’s what Grandma told me to do.” A recent study published in JAMA attempted to determine if half-dilute apple juice would be an acceptable oral rehydration option, and perhaps prove that grandmas sometimes do know best.

BRUE, The New ALTE

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Author: Danielle Goodrich, MD PGY-3
Stanford/Kaiser Emergency Medicine

In May, the American Academy of Pediatrics published new clinical guidelines to replace ALTE (Apparent Life-Threatening Events) with BRUE, Brief Resolved Unexplained Event. The new guidelines, in addition to defining BRUE, offer an approach to evaluation based on risk of repeat event or serious underlying disorder. The goal of the clinical guidelines is to better inform care while reducing costly and unnecessary interventions. The guidelines were devised from a comprehensive literature review of articles related to ALTEs from 1970 to 2014.

BRUE describes an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, now resolved episode with one or more of the following: (1) cyanosis or pallor, (2) absent, decreased or irregular breathing, (3) marked change in tone, and (4) altered level of responsiveness. The diagnosis is made when there is no explanation for a qualifying event after a thorough history and physical exam. BRUE and ALTE definitions differ as BRUE characterizes the event based on physician not caregiver observations and includes an age limit.

Tips for Tackling the Pediatric Trauma

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Author: Shyam Sivasankar, MD
Emergency Medicine Resident
Stanford-Kaiser Emergency Medicine
AAEM/RSA Publications Committee Member

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I am very fortunate to train at a facility with a child life specialist present in the emergency department. Their presence has helped me learn a lot about running pediatric trauma surveys and resuscitations, and I have picked up a few pearls along the way. The following are some of their tips, tricks, and suggestions.


1. Calming Distractions 

A trauma resuscitation can be quite overwhelming for an adult, let alone for a child. Use age appropriate interventions for each child including, but not limited to:

• Infants and Toddlers:
• Stuffed animals (for comfort) 

• Bubbles (to encourage deep breathing and relaxation) 

• Elmo Calls (Facetime™ with Elmo, a fun game for distraction) 

• School Age/ Teens: 
• iPads (or smart phones for distraction and teaching moments with patients) 

• Simply Sayin’ (a smart phone application, created in part by Phoenix Children’s Hospital. This application provides illustrations, a free-draw option, and video clips to help both patients and their parents understand what is happening while simultaneously lowering the anxiety level in the room.) 

• Stress ball for relaxation and stress management 

• Deep breathing techniques to support relaxation  

Why Will This Baby Not Stop Crying?

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Author: Josh Bowers, DO
Emergency Medicine Resident
Adena Regional Medical Center

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It is 3:00 am and a mother brings in her crying infant. The mother seems to be at a loss and states:

“Nothing I do will make him stop crying.”

The crying infant is a common complaint of parents [1,2,3] and a difficult diagnostic problem for emergency physicians. The etiology of an infant’s crying can range from normal patterns of infant crying to life threatening conditions. As emergency physicians, it is our job to differentiate between the benign and not-so-benign reasons for persistent crying and treat accordingly. Not only is it tough to take care of a patient that cannot verbalize their complaint, but it is even more challenging when you have had no previous interaction with the patient. [2]

Treatment of Diphenhydramine Cardiotoxicity

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Author: Teng Lu, MD
Emergency Medicine Resident
Stanford-Kaiser Emergency Medicine Residency

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Case
A 16 year old girl was brought in by family for ingestion of an unknown amount of diphenhydramine (Benadryl®) in a suicide attempt. Initial vitals were remarkable for sinus tachycardia at a rate of 120. Her mental status was sleepy but responsive to speech with occasional coherent answers. On EKG her QRS interval was noted to be mildly widened at 108 msec. She was given multiple doses of sodium bicarbonate in the emergency department. Around 45 minutes after arrival, she had a witnessed generalized tonic clonic seizure which self-resolved. She was admitted to the pediatric intensive care unit for neurologic and cardiac monitoring.

Pearls
Diphenhydramine is a first generation antihistamine that also has anticholinergic properties (competitive antagonist at muscarinic receptors). Because of its lipophilic structure, it easily crosses the blood brain barrier. General anticholinergic symptoms include paradoxical agitation, hallucinations, seizures, cerebral edema, rhabdomyolysis, tachycardia, hypertension, hyperthermia, flushed/dry skin, urinary retention, and mydriasis.

The severity of symptoms increase with dose ingested:

• 0.05-0.2 mg/day: therapeutic dose
• 0.6-1.0 g: Minor symptoms – somnolence, tachycardia (<160/min), nausea/vomiting, 
• 1.0-1.5 g: Moderate symptoms - agitation, confusion, hallucinations, ECG disturbances 
• >1.5 g: Severe symptoms - delirum/psychosis, seizures, coma

Deaths occur due to cardiac toxicity, as diphenhydramine has type IA sodium channel blockade properties.

ECG changes are similar to tricyclic antidepressant (TCA) cardiotoxicity:

• wide complex tachycardia
• R’ in aVR 
• S wave in leads I, aVL

Treatment for cardiac toxicity is sodium bicarbonate (just like TCA toxicity), however much of the evidence regarding treatment is based on case reports. Case reports also suggest some benefit with intralipid use in severe cardiac or neurotoxicity. As always involve Poison Control Center early at 1 (800) 222-1222.


References:

Abdelmalek D, Schwartz ES, Sampson C, Halcomb SE, McCammon C, Arroyo-Plasencia A, Stenger A, Krehbiel N, Mullins ME. Life-threatening diphenhydramine toxicity presenting with seizures and a wide complex tachycardia improved with intravenous fat emulsion. Am J Ther. October 3 2013; Epub ahead of print.

Pragst F, Herre S, Bakdash A. Poisonings with diphenhydramine – a survey of 68 clinical and 55 death cases. Forensic Sci Int. 2006 Sep;161(2-3):189-97.

Radovanovic D, Meier PJ, Guirguis M, Lorent JP, Kupferschmidt H. Dose-dependent toxicity of diphenhydramine overdose. Hum Exp Toxicol. 2000 Sep;19(9)489-95.

Sharma AN, Hexdall AH, Chang EK, Nelson LS, Hoffman RS. Diphenhydramine-induced wide complex dysrhythmia responds to treatment with sodium bicarbonate. Am J Emerg Med. 2003 May;21(3):212-5.