POTD: Foreign bodies, Ears!

This is a two part series for POTD. Foreign bodies: Ears and Nose! Today, Ears!

Quick Anatomy review to help locate that FB:

•        Anatomy

–       medial 2/3 is fixed in temporal bone –where many FBs are lodged and/or where trauma

•        Ask yourself: is it graspable or non-graspable?

–       Graspable: 64% success rate, 14% complication rate

–       Non-graspable: 45% success rate, 70% complication rate

•        What instrument/method should I use for what?

–       Alligator forceps: think something graspable like paper, foam

–       Suction tip: think something non graspable like a round object such as a bead

–       Irrigation: think something non graspable like a bead (note: do not irrigate organic material as will swell or break apart)

–       Glue: something non graspable like a bead or organic material that might swell or break if irrigated

Pearls on insect FB:

·       Kill it first. They will fight.

-        What to use? Lidocaine jelly, viscous lidocaine (2%), lidocaine solution, isopropyl alcohol, or mineral oil.

-        After they are dead, you can remove or can send to ENT for removal (most patients will want it out, can you blame them?)

o    An ENT friend of mine says to keep the insect in the ear and let them remove because we tend to cause trauma. Something to keep in mind.

What if I caused or the FB (like that insect fighting for their life) caused local trauma?

•        TM rupture?

–       Keep dry

•        When to use otic abx drops

–       Any trauma or dirty FB injury (think: that insect crawling around) or canal lacerations/abrasions.

–       What to give? Ofloxacin drops or the very expensive ciprodex.

•        ENT f/u

Pitfalls

•        Inspect after removal

–       Something else in there? Abrasions/trauma and need prophylactic antibiotic ear drops

•        If at first you don’t succeed, try again. But consider changing the technique of removal. Remember the law of diminishing returns.

References:

Pem playbook: excellent peds podcast by Dr.  T Horeczko - ‎2015

Wiki EM: Ear foreign body

It's getting hot in here - Pediatric Fevers

So, it's winter. Kids get sick. But really, 8-10 times a year is normal, so they're sick all the time! And they present to the ED with FEVER!!!!

What do you think about and what do you do with FEVER!?!?!?

- Fever = 38 degrees Celsius or 100.4 Fahrenheit

- Subjective fever per parents? Believe and work up/treat appropriately based on clinical presentation

- Determine exact onset and calculate fever duration (if since last night, it is only 1 day since <24 hours)

- Ask T-max
Thorough exams must include throat, ears, skin, oropharynx!

If suspect infectious etiology, treat with antipyretics:

Acetaminophen: 15 mg/kg every 4 hours, PRN

Ibuprofen (6 months and older): 10 mg/kg every 6 hours, PRN

The "alternating" approach of treating every 3 hours (Acetaminophen at 9, Ibuprofen at 12, Acet. at 3, etc) can help keep the kiddos' fever under control and keep them happy, hydrated, and hopefully home!

What to do!?

0-28 days infant: 

Orders: CBC with differential, Blood Culture, BMP, UA with culture, LP with CSF gram stain/cell count/culture/possible viral culture. +/- HSV PCR. +/- stool culture if presenting with diarrhea. CXR

Pathogens: Group B Strep, E. Coli, Listeria. Consider HSV

Treatment: Ceftazidime or cefotaxime + Ampicillin (for Listeria). or Gentamycin + Ampicillin. +/- Acyclovir (< 21 days, seizures, rash, mom w/ lesions)

**No ceftriaxone: ceftriaxone displaced bilirubin and places patient at increased risk for Kernicterus 

Dispo: Admit

29-60 days Infant: 

Similar to above, but more experienced pediatric clinicians may use clinical judgement regarding LP. In general, most general EM physicians should practice more conservative management and pursue LP. 

*Philadelphia/Rochester/Boston criteria for infants vary, hence the debate.*

Orders: CBC with differential, Blood Culture, BMP, UA with culture, LP with CSF gram stain/cell count/culture/possible viral culture. +/- HSV PCR. +/- stool culture if presenting with diarrhea. +/- CXR if respiratory symptoms. 

Treatment: Ceftazidime or cefotaxime + Ampicillin or Ceftriaxone. Skin infection: +vancomycin

Dispo: often admit, but again, clinical judgement. If you diagnose a UTI in a well appearing, eating infant and labs are normal WBCs, no bandemia, normal CSF, consider 1 dose of ceftriaxone and 24 hour follow up (be mindful of patient's family's education, access to healthcare/the hospital, reliability, health literacy, etc.). Do what is best for the patient. See reference from CHOP for an example:  https://www.chop.edu/clinical-pathway/febrile-infant-emergent-evaluation-clinical-pathway. Again - do what is best for the patient and appropriate for your level of pediatric training/experience. 

Acute Otitis Media: 

Bacteria: Strep pneumo (~80%), H. flu (especially if unvaccinated), Moraxella

Treatment: high dose Amoxicillin 90 mg/kg per day divided into 2 doses (to overcome strep pneumo's penicillin binding protein and H. flu's beta lactamase). If resistant, Augmentin (dose based off the amoxicillin) 

Pneumonia: 

Most common pathogens: 

< 3 weeks: E. coli, Group B Strep, Listeria

> 3 weeks: Strep pneumonia

UTI: 

RSV/Bronchiolitis: Usually < 2 years old. Supportive care, often HFNC. Babies < 6 months are high risk and give good return precautions if child is well enough to go home.

Influenza: keep in mind children < 5 are all high risk, but children < 2 are at greatest risk. 

Treat with oseltamivir, even if after 48 hours for high-risk patients (young, immunosuppressed, asthmatic, renal disease, DM, neuromuscular disease, pregnant, long term care facilities). 

Oseltamivir dosing is BID for 5 days: <1 year old: 3 mg/kg. >1 year old and 15 kg or less: 30 mg. 

15-23 kg: 45 mg.  23-40 kg: 60 mg. > 40 kg: 75 mg.

Group A Strep Throat: Under 3 years old, do not develop Rheumatic heart disease so often do not require antibiotic treatments

Treatment: Low dose Amoxicillin. 45 mg/kg divided into 2 doses. 

Pyogenic Joint Infection: Most common age group is < 3 years old. 

Pathogen: Staph aureus is the most common pathogen and often with preceding trauma or URI

Treatment: Need ortho consult and include MRSA antibiotic coverage

References:

https://www.chop.edu/clinical-pathway/febrile-infant-emergent-evaluation-clinical-pathway

Harriet Lane - the whole book is a reference gem, but looked up each topic

Pediatric Nutrition

To supplement our new pediatric reference cards, I've included some things in this e-mail which were not covered.

Weight Gain

• Proper weight gain is 25-30 grams/day for first 4-6 months.

• After 4-6 months patients should double their birth weight.

• Patients regain birth weight by 10-14 days.

Pediatric Fluid Resuscitation

• Bolus: 20mL/kg

  • Remember, in sepsis can do 3x bolus = 60 mL/kg

• Maintenance Fluids - The 4-2-1 rule

  • Add the following for each 10kg of body weight:

  • 4mL/kg

  • 2mL/kg

  • 1mL/kg

  • e.g. 24 kg child = (4mL*10mL/kg) + (2mL*10mL/kg) + (1mL*4mL/kg) = 64 mL/kg

Pediatric Dextrose/Hypoglycemia Resuscitation

• The dextrose Rule of 50

  • Multiple your % dextrose solution supplied in ED by the ml/kg to give to patient to give and set equal to 50

  • In other words, divide 50 by the % dextrose solution you have available

  • For D10: 10X=50 i.e. give 5mL/kg of D10

  • For D25: 25X=50 i.e. give 2mL/kg of D25

  • For D50: 50X=50 i.e. give 1mL/kg of D50

Pediatric wet diaper output

• Proper output is 1-2ml/kg/hr

• Practically, patients should have 4-6 wet diapers per day.

  • Remember to base this off patient's "normal" as some parents do not change diapers as often.