Pediatric Emergency Medicine Practice

Sepsis is a leading cause of morbidity and mortality in children. Early recognition and timely initiation of empiric broadspectrum antibiotics and crystalloid fluid administration have been associated with better outcomes. Although evidence for diagnosis and treatment of septic shock was first generated in adult studies, it is clear that pediatric studies are needed for management of septic shock in children. This issue provides guidance for managing septic shock in children, with a focus on early recognition and appropriate resuscitation...

The advent of pneumococcal and Haemophilus influenzae vaccines has substantially reduced the risk for occult (unsuspected) serious bacterial infection or invasive bacterial infection in the febrile child. The challenge for emergency clinicians is to identify and treat children with serious illness while avoiding overtreatment. This issue reviews the epidemiology and management of fever in children aged 3 to 36 months, focusing primarily on previously healthy, well-appearing children without a source of fever whose evaluation and management are more ambiguous...

Imaging is a critical tool for the diagnosis and management of thoracic and abdominal injuries in pediatric patients. The location and mechanism of injury, the physical examination, and other clinical findings should guide emergency clinicians in the selection of the most appropriate imaging modality for the pediatric trauma patient. This supplement reviews the evidence for imaging decisions in the setting of pleural space, lung parenchyma, chest wall, cardiac, diaphragm, solid-organ, and hollow-viscus injuries in pediatric patients...

Ocular injuries are the most common cause of preventable blindness in children. A detailed and systematic evaluation of patients with ocular trauma will reduce morbidity and improve long-term vision outcomes. This issue reviews the critical aspects of the pediatric ocular examination for accurate diagnosis of vision-threatening injuries. It also provides recommendations for immediate emergency department treatment, and indications for urgent versus emergent ophthalmology referral.

Firearm injuries are a leading cause of pediatric mortality in the United States. The frequency of pediatric extremity firearm injuries and the high repeat incidence in high-risk patients make it important for emergency clinicians to understand how to manage these injuries. This issue focuses on the acute management of firearm injuries to the extremities of pediatric patients, drawing from the pediatric literature or extrapolated from adult literature where pediatric evidence is scarce. Current trends, novel management, and controversies are also discussed...

Labor and sex trafficking impact children of all ages, genders, and nationalities. Trafficked patients present to the emergency department for illnesses and injuries both related and unrelated to their trafficking experiences. Emergency clinicians are not meant to be experts in labor and sex trafficking, but they must know enough to be able to identify patients at risk for trafficking and ensure that these patients have the opportunity to be connected to relevant services and support. This issue reviews the ways in which youth are trafficked, the indicators of trafficking, and the evidence-based and best-practice recommendations for addressing suspected or confirmed trafficking in the pediatric and adolescent patient populations...

Drowning and submersion injuries are highly prevalent, yet preventable, causes of pediatric mortality and morbidity. Prehospital care should focus on restoring normal ventilation and circulation as quickly as possible to limit the extent of hypoxic insult. Diagnostic testing for symptomatic patients may include blood glucose level, arterial blood gas level, complete blood count, electrolyte levels, chest radiography, and cardiorespiratory monitoring with pulse oximetry and a rhythm strip. In this review, passive external, active external, and active internal rewarming techniques for treatment of hypothermic patients are discussed...

Although rare in children, spinal epidural abscess (SEA) is a rapidly progressive clinical entity that can lead to irreversible neurologic damage if untreated. The rarity and variability in presentation can lead to initial misdiagnosis. Diagnosis requires a high index of suspicion and is often delayed until neurologic deficits are present. This issue reviews key findings on the history and physical examination that are associated with SEA, provides guidance for the laboratory tests and imaging studies that are indicated once SEA is suspected, and discusses treatment options based on current evidence...

A review of the uses and evidence for the Bacterial Meningitis Score, which rules out bacterial meningitis in pediatric patients.

A review of the uses and evidence for the Local Anesthetic Dosing Calculator, which is used to help avoid toxic doses local anesthetics.

Analgesia in pediatric patients is critical for minimizing discomfort and maximizing satisfaction for both the patients and their caregivers. In the last decade, ultrasound has been shown to be effective in improving the safety and efficacy of regional anesthesia. This issue discusses materials, methods, and monitoring for pediatric patients undergoing nerve blocks in the emergency department, including both ultrasound-guided and landmark approaches. Special considerations for pediatric patients are reviewed, including maximum dosages of local anesthetic and how to perform nerve blocks safely in patients with different developmental abilities and in medically complex children...

Millions of children continue to be at risk for lead exposure despite a dramatic decline over the past 4 decades, and hundreds present annually to emergency departments with lead poisoning. These patients can be challenging to identify due to their nonspecific presentation and frequent lack of known exposure. This issue will prepare the emergency clinician to identify and care for the lead-poisoned patient, focusing on: (1) identifying key historical features, signs, and symptoms at presentation; (2) the medical management of lead poisoning; and (3) formulation of a safe discharge plan...

A review of the uses and evidence for the Step-by-Step approach, which identifies febrile infants aged ≤90 days who are at low risk of invasive bacterial infections.

Specific biomarker levels can help differentiate children who require emergent medical interventions, such as procedures, surgeries, or antibiotics, from those who may not. Appropriate application of biomarkers after a thorough history and physical examination can potentially improve cost-effective management by minimizing unnecessary procedures and tests without sacrificing patient safety. This issue reviews the literature regarding 4 biomarkers: lactate, C-reactive protein, ferritin, and procalcitonin. Evidence-based recommendations are made for the clinical evaluation of bacterial meningitis, common infections, and appendicitis...

Pediatric chest pain is a relatively common presenting complaint, but identifying serious pathologies without overtesting patients with less-serious pathologies can be a challenge for emergency clinicians. This issue reviews the available literature to provide evidence-based recommendations to support a more standardized approach to the evaluation and management of pediatric patients with chest pain. This issue will help the emergency clinician identify red flags associated with cardiac causes of pediatric chest pain, recognize life-threatening causes of cardiac and non- cardiac chest pain, clinically diagnose the most common causes of non-cardiac chest pain, and appropriately utilize diagnostic tests in the evaluation of chest pain patients...

A review of the uses and evidence for the Hour-specific Risk for Neonatal Hyperbilirubinemia tool, which predicts risk of hyperbilirubinemia in neonates.

Hyperbilirubinemia is one the most common reasons for emergency department visits for the neonate. Most cases of unconjugated hyperbilirubinemia are benign. Although rare, unrecognized or untreated pathologic unconjugated hyperbilirubinemia can lead to the development of acute bilirubin encephalopathy and, ultimately, kernicterus. This issue reviews the emergency department evaluation and management of neonatal hyperbilirubinemia and discusses how to recognize acute bilirubin encephalopathy, with the goal of preventing kernicterus...

Electrical injuries in pediatric patients are uncommon but can be life-threatening and require efficient and effective identification and management. Injury severity is based on the characteristics of the electricity, the duration of contact with the electrical source, and the current's pathway through the body. This issue discusses the specific threats posed by high-voltage, low-voltage, and lightning injuries. The various presentations are described, including burns, arrhythmias, respiratory arrest, cardiac arrest, blunt trauma from falls or blast events, rhabdomyolysis, tympanic membrane rupture, and altered mental status, among others...

Global travel has made travel-associated infectious diseases (TAIDs) a more frequent consideration in the pediatric emergency department. Studies show that physicians may either omit a travel history or, even with a positive travel history, do not consider potentially serious illnesses, such as dengue and malaria. A thorough travel history including the purpose, location, activities, diet, and exposures can help the emergency clinician develop and narrow the differential diagnosis. This issue reviews the epidemiology, clinical presentation, diagnosis, and management of various TAIDs, with the goal of early recognition and disease-specific treatment...

Transplant patients are at risk for illnesses and complications days, months, or years after transplantation, and they can present complex challenges for emergency clinicians. This review discusses the general approach to the management of pediatric transplant patients in the emergency department, with a focus on general complications and organ-specific complications after solid organ transplantation. Hematopoietic stem cell transplantation and its common complications will also be discussed. A key step in the management of all transplant patients includes consultation with the patient's transplant team to ensure appropriate testing, treatment, and disposition for these patients...