69 episodes

You make tough calls when caring for acutely ill and injured children. Join us for strategy and support -- through clinical cases, research and reviews, and best-practice guidance in our ever-changing acute care landscape.

Please visit our site at http://PEMplaybook.org/ for show notes and to get involved with the show -- see you there!

Pediatric Emergency Playboo‪k‬ Tim Horeczko, MD, MSCR, FACEP, FAAP

    • Medicine
    • 5.0 • 1 Rating

You make tough calls when caring for acutely ill and injured children. Join us for strategy and support -- through clinical cases, research and reviews, and best-practice guidance in our ever-changing acute care landscape.

Please visit our site at http://PEMplaybook.org/ for show notes and to get involved with the show -- see you there!

    Constipation and the way out

    Constipation and the way out

    Constipation as a diagnosis can be dangerous, mainly because it is a powerful anchor in our medical decision-making. Chances are, you’d be right to chalk up the pain to functional constipation — 90% of pediatric constipation is functional, multifactorial, and mostly benign — as long as it is addressed.
    We’re not here for “chances are“; we’re here for “why isn’t it?“
    Ask yourself, could it be:
    Anatomic malformations: a**l stenosis, anterior displaced anus, sacral hematoma
    Metabolic: hypothyroidism, hypercalcemia, hypokalemia, cystic fibrosis, diabetes mellitus, gluten enteropathy
    Neuropathic: spinal cord abnormalities, trauma, tethered cord
    Neuromuscular: Hirschprung disease, intestinal neuronal dysplasia, myopathies, Down syndrome, prune belly syndrome
    Connective tissue disorders: scleroderma, SLE, Ehlers-Danlos syndrome
    Drugs: opioids, antacids, antihypertensives, anticholinergics, antidepressants, sympathomimetics
    Ingestions: heavy metals, vitamin D overload, botulism, cow’s milk protein intolerance
     
    Red Flags Failure to thrive
    Abdominal distention
    Lack of lumbosacral curve
    Midline pigmentation abnormalities of the lower spine
    Tight, empty rectum in presence of a palpable fecal mass
    Gush of fluid or air from rectum on withdrawal of finger
    Absent a**l wink
     
     
     
    You gotta push the boat out of the mud before you pray for rain.
     
    — Coach  
     
    Medications for disimpaction (do this first!) Polyethylene Glycol (PEG) 3350 (Miralax): 1 to 1.5 g/kg PO daily for 3 to 6 consecutive days.  Maximum daily dose: 100 g/day PO.  Follow-up with maintenance dose (below) for at least 2 months (usually 6 months)
    Lactulose: 1.33 g/kg/dose (2 mL/kg) PO twice daily for 7 days
    Mineral Oil (school-aged children): 3 mL/kg PO twice daily for 7 days
     
    Medications for Maintenance (do this after disimpaction!) Polyethylene Glycol (PEG) 3350 (Miralax): 0.2 to 0.8 g/kg/day PO.  Maximum daily dose: 17 g/day. Maintenance dosing for Miralax may need to be tailored; up to 1 g/day maintenance.  
    Lactulose: 1 to 2 g/kg/day (1.5 to 3 mL/kg/day)PO divided once or twice daily.  Maximum daily dose: 60 mL/day in adults.
    Mineral Oil: 1 to 3 mL/kg/day PO divided in 1 to 2 doses; maximum daily dose: 90 mL/day
    Docusate (Colace): 5 mg/kg/day PO divided QD, BID, or TID (typical adult dose 100 mg BID)
    Senna, Bisocodyl — complicated regimens; use your local reference
     
    Enemas Are you sure?  Have you tried oral disimpaction over days? No phosphate enemas for children less than 2. Saline enemas are generally safe for all ages Be careful with the specific dose — please use your local reference  
    Selected References
    Freedman SB et al. Pediatric Constipation in the Emergency Department: Evaluation, Treatment, and Outcomes. JPGN 2014;59: 327–333.

    North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition. Clinical Practice Guideline: Evaluation and Treatment of Constipation in Infants and Children. JPGN 2006; 43:e1-e13.

    Tabbers MM et al. Evaluation and Treatment of Functional Constipation in Infants and Children: Evidence-Based Recommendations From ESPGHAN and NASPGHAN. JPGN 2014;58: 258–274.
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    • 48 min
    Pediatric IV Tips and Tricks

    Pediatric IV Tips and Tricks

    Top 10 [details in audio] Set the stage – exude confidence and be prepared Choose the right cannula size – a smaller working IV is infinitely better than none Feeling is better than looking – trust yourself Mark the site – things get wonky when you take your hands off to disinfect Tourniquets can mess you up – try to use a holder’s hand to occlude the vein The holder rules – get as many hands on deck as you need. Tension is good –  a little counter traction on the skin with your non-dominant hand helps to decrease the friction as the needle goes through the fascial layers. Stay in line – your needle is an extension of your arm Gravity is your friend – the kinder, gentler tourniquet The 3 Fs – flash, flatten, and forward. Get the flash at a 30 degree angle, flatten that angle, (advance another 1mm), and advance the plastic catheter over the needle into success

    • 26 min
    Vagal Maneuvers In Children

    Vagal Maneuvers In Children

    https://pemplaybook.org/?p=2234

    • 28 min
    Conjunctivitis

    Conjunctivitis

    • 44 min
    Go or No Go: Pediatric Presedation Assessment

    Go or No Go: Pediatric Presedation Assessment

    https://pemplaybook.org/?p=2211

    • 43 min
    Caustic Ingestions

    Caustic Ingestions

    https://wp.me/p6B1Mm-zr

    • 32 min

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