The pediatric and gravid populations have special needs regarding imaging for abdominal pain. This article reviews the more common causes of abdominal pain in children and pregnant women and how to approach imaging in these populations.
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Neonatal Resuscitation Highlights Author: Geoff Jara-Almonte, MD (PEM Fellow, NY Methodist Hospital) // Edited by: Jennifer Robertson, MD and Alex Koyfman, MD (@EMHighAK) You are midway through an overnight shift in a suburban emergency department (ED) when a young woman is dropped off by her partner in labor. The triage nurse brings her to an exam room and she is placed on the cardiac monitor. Her vital signs are a temperature of 38.5° Celsius (C), a heart rate (HR) of 123, and a blood pressure (BP) of 110 /67 mm Hg. Between contractions, the patient tells you that this is her 4th pregnancy, is approximately 8 or 9 months pregnant and that she has not had any prenatal care. She also tells you that all of her prior deliveries were “fast”. As you try to decide what to do next, the patient has another contraction and feels an unbearable urge to push. You see the fetal head at the perineum, and note thick meconium-stained amniotic fluid. You realize that the infant is likely distressed and may require resuscitation. You try to recall the general priorities of neonatal resuscitation. Most infants transition from intrauterine to extrauterine life without any assistance. The term-infant with good tone, color, and respiratory effort requires no assistance and should be handed off to the mother after birth. However, approximately 10% of infants require some resuscitation and about 1% require extensive resuscitation.[1] The main priority in neonatal resuscitation is establishment of effective ventilation and oxygenation. The first step is an initial trial of basic supportive measures including cleaning, drying and stimulating the infant. If there is poor tone or respiratory effort, try stimulating by gently slapping the feet. If there is airway obstruction, attempt repositioning – place the infant in the “sniffing” position. If the airway obstruction is due to secretions, attempt gentle suctioning with bulb suction or a soft suction catheter. Heat loss should also be minimized. Infants should be dried quickly and wet blankets or towels discarded. Vigorous infants who require no resuscitation should be swaddled in warm dry blankets or placed directly on the mother’s skin. If resuscitation is required, the infant should be placed in an isolette under a radiant warmer. Low birth weight infants are at a greater risk of hypothermia. Those infants less than 1,500 grams (gm) should be wrapped in medical or food grade plastic bag to prevent evaporative cooling. As your nurse pulls out the precipitous delivery pack, you prepare for the delivery by turning on the radiant warmer and connecting the suction and supplemental oxygen. Soon, with a final contraction, a male infant is delivered. You estimate that he weighs about 3.5 kilograms (kg), and appears near term. However, you also notice that he is meconium stained and is cyanotic with minimal respiratory effort. You realize that this meconium stained neonate is going to require resuscitation. Aspiration of any amount of meconium-stained amniotic fluid, whether intrauterine, intra-partum or post-partum can lead to the development of meconium aspiration syndrome (MAS). Fortunately this syndrome complicates only 2 to 5% of meconium births. The severity can range from mild tachypnea to severe pneumonitis. In order to reduce the risk of MAS, older guidelines advocated routine intrapartum suctioning between delivery of the head and shoulders, but this practice has been shown to be ineffective.[2] Routine intubation and endotracheal suctioning of all infants with thick meconium was historically recommended as well, however this has been shown to be ineffective and is no longer standard practice.[3] Current management of the infant born with meconium-stained amniotic fluid depends on the clinical status of the child. A vigorous infant can be managed with supportive care and oral and nasal suctioning, if indicated. Non-vigorous infants should have endotracheal suctioning performed prior to other resuscitative measures. To perform endotracheal suctioning, a meconium aspirator is attached to suction and an endotracheal tube. The infant is then intubated with direct laryngoscopy. Next, the vent port on the meconium aspirator is occluded and the endotracheal tube is slowly withdrawn. The used tube is then switched for a clean one, the infant is re-intubated, and the process is repeated. The procedure is repeated until clear secretions are aspirated. If there is a significant delay in or difficulty intubating the infant, consider omitting this step and proceeding to positive pressure ventilation (PPV), especially if there is persistent bradycardia. You quickly hook the meconium aspirator to wall suction and attach the other end to the endotracheal tube. You carefully advance the laryngoscope, lift the epiglottis and see the cords. You easily pass the tube. You occlude the suction port on the meconium aspirator and slowly withdraw the tube that contains thick secretions. You leave the blade in place have your nurse quickly replace the tube and perform a second round of tracheal suctioning. This time you have only scant secretions in the tube. You decide that no additional suction is needed. You quickly dry the infant and discard the wet towels. You palpate his pulse at the umbilical stump and note a heart rate of only 50 beats per minute (bpm) and ineffective gasping respirations. You try and decide what the next step should be. The American Heart Association (AHA) and Neonatal Resuscitation Program (NRP) algorithms allow only 30 seconds to perform the basic supportive measures discussed above. In the case of a non-vigorous meconium-stained infant, basic measures are skipped in favor of immediate endotracheal suctioning. Importantly, bradycardia (HR < 100 bpm) or cyanosis that persists after any step requires the initiation of positive pressure ventilation. Those infants with adequate respiratory effort and heart rate who remain persistently cyanotic should be given supplemental O2 and placed on the pulse oximetry (SpO2) monitor. The SpO2 probe should be placed on the right upper extremity to obtain a pre-ductal value. It is usually placed on the thenar eminence. Placing the probe on the child prior to turning on the monitor may facilitate a more rapid signal acquisition.[4] Controversy exists regarding the concentration of oxygen to use
Neonatal Resuscitation Read More »
Pediatric Medical Resuscitation Pearls and Pitfalls: The Airway Author: Geoff Jara-Almonte, MD // Editor: Alex Koyfman, MD (@EMHighAK) Featured on #FOAMED REVIEW 39TH EDITION – Thank you to Michael Macias from emCurious (@EMedCurious) for the shout out! You are one hour into your overnight shift at a single-coverage semi-rural emergency department when you are paged overhead to the resuscitation room. As you come in you see your triage nurse rushing back with a young couple holding a boy who looks to be about two years old. He is in severe respiratory distress. You place him on the monitor, his vital signs are HR 145, SpO2 95%, tympanic temperature 36.7, he is breathing 32 times a minute. You place him in his father’s lap on the stretcher and examine him. His neck is flexed and head extended. He has supraclavicular retractions and nasal flaring. His lungs are clear, there is soft inspiratory stridor. No trismus, the oropharynx looks normal, neck is supple with no adenopathy or masses. You try and decide what is causing his respiratory distress . . . In children the combination of history and exam is often sufficient to determine the cause of respiratory distress as well as assess the degree of severity. Particularly helpful findings include: Stridor- suggestive of upper airway obstruction; respiratory phase may help localize lesion: Inspiratory – obstruction in supraglottic area or immediately at the level of the glottis Biphasic – obstruction in the trachea Expiratory – carina or below Retractions may be subtle, require careful observation of unclothed child, indicate increased work of breathing. Tend to progress from inferior to superior with increasing distress. Tachypnea – may be the only sign of significant respiratory distress, especially in young infants. Prolonged observation is necessary, as periodic breathing can lead to under- or overestimation. Position – sniffing position indicates airway obstruction, tripoding usually with lower airway pathology. Nasal Congestion – can precipitate significant respiratory distress in neonates and infants under 4 months of age who are obligate nasal breathers Grunting – creates PEEP usually indicates alveolar pathology Nasal Flaring – reflexive activity, usually with upper airway obstruction. Paradoxical or see-saw breathing – chest collapse and abdominal protrusion during inspiration is an ominous sign of respiratory muscle fatigue.[i] Head Nodding – associated with impending respiratory failure and mortality[ii] You decide he likely has an upper airway obstruction of some sort. You get a bit more history from the parents – they tell you he has no medical problems, and was in his usual state of health until tonight. He was playing with his older sister in her room unsupervised for about ten minutes when they heard crying. They rushed in and found him in distress. You quickly run over the differential of acquired upper airway obstruction in children . . . Epiglottitis – Usually febrile and toxic-appearing. Rapid onset, present after <24 hr of symptoms. Drooling, trismus, odynophagia, and respiratory distress are common presentations. Retropharyngeal and parapharyngeal abscesses – Often polymicrobial, associated with sore throat, high fever, muffled voice, trismus, and neck stiffness, usually less than 3y/o Croup – Most common cause of obstruction, peak at 2yr. Harsh barking cough, inspiratory stridor, preceded by URI. Usually worse at night and improves in cold air Bacterial tracheitis – usually viral prodrome, may have acute onset of respiratory distress. Febrile, sometimes toxic appearing. Difficult to differentiate from croup and epiglottitis. Aspirated foreign body – Sudden in onset, no associated infectious symptoms. Peak age in toddler years. Variable history of choking episode.[iii] Based on this history you suspect an aspirated foreign body. As you are trying to decide what to do next you place him on a non-rebreather. He gets upset with the mask on his face and fights to take it off. As he is crying and becoming more distressed, you hear his stridor worsening. He begins to have severe retractions, and you notice some perioral cyanosis. His pulse ox drops to the 80s. You try and decide if it’s more important that he have the O2 mask on, or that he be comfortable . . . Agitation and crying can precipitate worsening respiratory distress and decompensation of a tenuous patient. Crying and hyperventilation lead to increased minute ventilation, which in turn leads to increased airflow velocity across the site of obstruction. As airflow velocity increases, there is increasingly negative intraluminal pressure (Bernoulli’s principle). As intraluminal pressure drops, there is worsened dynamic inspiratory collapse of the pliable airway soft tissues, which leads to worsened obstruction and increasing distress. [iv] Keeping your patient as calm as possible can reduce the possibility of sudden decompensation. Allow the child to maintain a position of comfort. Allow him to sit in a parent’s lap or be near a parent if at all possible. Minimize noxious stimuli such as blood-pressure cuffs, rectal thermometers, phlebotomy, and oxygen masks or nasal cannula as much as possible. Try alternatives like blow-by oxygen or nebs. Consider inhaled steroids for croup. Try to limit the number of caregivers in the room. Remember that children take their behavioral cues from their parents, and the parent will take them from you. Be as calm and reassuring as possible. Allow the child access to a favorite toy, video game, or phone. You decide to allow him to take off the mask. You have the father hold it and give blow-by oxygen. Over the next few minutes he stops crying. His stridor and retractions improve a little. But he remains distressed, and seems worse than when he came in. You consider trying the Heimlich maneuver or looking in the mouth to see if there is a foreign body you could remove, but then you wonder if that would be a good idea . . . The preferable treatment for a child with a partially obstructing foreign body is endoscopic or surgical removal in the OR under controlled circumstances. So long as it remains a partial obstruction – the child is breathing, crying, or phonating and
Pediatric Medical Resuscitation – The Airway Read More »
While on shift at a busy urban emergency department, you are notified by EMS dispatch of an ambulance en-route with a patient involved in a high-speed MVC. They report she is a female, in her 20s or 30s, who is obviously gravid, but of unknown gestational age. According to EMS vital signs are: HR 104, RR 25, BP 104/54, and SpO2 98% on room air. They are requesting activation of your trauma team.
Resuscitation of the Pregnant Trauma Patient – Pearls and Pitfalls Read More »