Category: Pediatrics

Pediatric Seizures (2025)

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by Neema Francis, Faiz Ahmad, Thiagarajan Jaiganesh

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You Have A New Patient!

A 5-year-old female was brought into the ED as her parents noticed that she was not very responsive. She was diagnosed with otitis media 3 days ago and has been taking oral amoxicillin for it. This morning, she became irritable and was less active than usual. On arrival at the ED triage, the patient was tachypneic (40 bpm), tachycardic (145 bpm), and had a temperature of 39.4°C.

The image was produced by using ideogram 2.0.

The child did not respond to vocal stimuli but was opening her eyes spontaneously. She had a sluggish pupillary response to light, and she seemed unaware of her surroundings. Suddenly, the patient began seizing, with her eyes up-rolled and her hands clenched and stretched downwards.

What Do You Need To Know?

Importance

Pediatric seizures are a significant health concern due to their high incidence, diagnostic complexity, diverse causes, and potential for severe consequences. Seizures are among the most common neurological disorders in children, with approximately 4–10% experiencing at least one seizure by age 16 [1,2]. The incidence is highest in the first year of life and remains substantial throughout childhood, particularly in children under three years old [3]. Seizures can result from various causes, including fever, infections, genetic disorders, head injuries, metabolic disturbances, and structural CNS abnormalities, which often complicates diagnosis and treatment [3,4]. Prolonged seizures, such as status epilepticus lasting five minutes or more, can lead to lactic acidosis, neuronal injury, network alterations, or even neuronal death, particularly when lasting beyond 30 minutes [3]. These severe outcomes impact development, quality of life, and increase the risk of comorbidities such as intellectual disability, depression, and anxiety. Children with epilepsy face a 5–10 times higher mortality risk compared to their peers and are prone to medical complications and long-term educational and social challenges [3,5]. The condition places a significant burden on healthcare systems and induces considerable psychological stress on children and their families [6,7]. 

Epidemiology

Seizures affect up to 10% of children, with incidence rates ranging from 33.3 to 82 cases per 100,000 annually, peaking in the first year of life and declining during adolescence [6,8]. Most (94%) of children presenting to the emergency department (ED) with a first seizure are under 6 years of age [4]. Febrile seizures, the most common type in young children, affect 3–4% of all children, primarily those under five years old [5,6]. Neonatal seizures, with distinct characteristics due to brain immaturity, are a common neurological condition in newborns [9]. Key risk factors include a family history of seizures, fever, CNS infections (e.g., meningitis, viral infections), head injuries, pre-existing neurological conditions, and maternal factors such as alcohol use, smoking, and prenatal exposures [3,7].

Seizures can be symptomatic or idiopathic. Acute symptomatic seizures arise from recent events, while remote symptomatic seizures result from chronic conditions. Generalized tonic-clonic seizures are the most frequent type [4], while status epilepticus (SE), a critical condition, is often triggered by fever or CNS infections in children [3]. Genetic factors, metabolic disorders, electrolyte imbalances, and structural brain abnormalities are recognized as key causes [6]. Mortality in pediatric epilepsy is 2–4 times higher than the general population and significantly elevated in children with neurological comorbidities, with sudden unexpected death in epilepsy (SUDEP) as a leading cause [3]. Febrile seizures are often benign, but complex febrile seizures may increase the risk of future epilepsy [2,6]. 

Pathophysiology

The pathophysiology of pediatric seizures involves complex interactions of neuronal excitation and inhibition in the brain, influenced by age, developmental stage, and underlying conditions [9]. Seizures arise from abnormal, excessive, and synchronous neuronal activity, leading to transient signs and symptoms such as involuntary muscle activity [3,9]. This activity stems from an imbalance between excitatory and inhibitory neurotransmission.

Basic Mechanisms of Seizures

The primary mechanism behind seizures involves either a deficit in neuronal inhibition or an excess of excitatory stimuli. The inhibitory neurotransmitter gamma-aminobutyric acid (GABA) plays a crucial role. In mature brains, GABA inhibits neuronal firing, maintaining balance in the central nervous system [3]. However, in neonatal brains, the immature GABA system can paradoxically cause excitation, making neonates more susceptible to seizures [9]. Additionally, alterations in GABA function, such as receptor dysfunction, can lead to prolonged and high-intensity neuronal stimulation, further increasing excitability. Voltage-gated ion channels and excitatory neurotransmitters like glutamate also contribute to seizure generation. Glutamate receptors, such as NMDA and AMPA, are primary excitatory receptors in the CNS and are involved in seizure propagation.

Age-Related Factors and Neuronal Imbalance

The immature state of the neonatal brain predisposes it to seizures due to developmental differences. In early life, the formation of excitatory synapses occurs before the development of inhibitory synapses, contributing to an imbalance in neuronal activity [7,9]. Additionally, the GABA receptor in neonates can cause depolarization rather than hyperpolarization, further enhancing neuronal excitability. Ion channel imbalances, especially the premature maturation of channels involved in depolarization, exacerbate this vulnerability [7].

Specific Factors Contributing to Seizures

Several specific factors influence seizure pathophysiology:

  1. Genetic Factors: Mutations in genes regulating synapse development, ion transport, protein phosphorylation, and gene transcription can disrupt neuronal activity [7].
  2. Metabolic Disturbances: Conditions like hypoglycemia, hypocalcemia, hyponatremia, and other metabolic imbalances impair neuronal function, triggering seizures [2,3].
  3. Hypoxic Conditions: Perinatal asphyxia and hypoxic-ischemic encephalopathy damage brain cells, increasing seizure risk [2,6,7].
  4. Infections: CNS infections such as meningitis and encephalitis disrupt normal brain function, leading to seizures [2,4,10].
  5. Structural Abnormalities: Malformations of cortical development and acquired lesions alter neuronal networks, predisposing to seizures [2,9].
  6. Fever: Although the exact mechanism is unclear, fever lowers the seizure threshold in some children, particularly those prone to febrile seizures [2]. In febrile seizures, inflammatory mediators such as IL-1 have been shown to increase neuronal stimulation. Animal models and preliminary studies suggest that these mediators play a role in seizure pathophysiology, although the clinical significance remains under investigation.

Medical History

A detailed history is crucial for accurately diagnosing and managing seizures in children. The history should focus on the events immediately preceding the seizure, the seizure itself, and the period following the seizure. It is important to obtain information from the child (when possible) and any witnesses [2]. When taking a medical history for pediatric seizures in the emergency department, it is important to gather information about the following key features [2,3,7-9,11,12]:

1. History of Present Illness:

  • Onset and duration of seizures: This information helps determine the type and underlying cause of the seizure. Note how the event began, including any preceding aura. An aura is a subjective sensation or experience that may precede a seizure [2,9].
  • Precipitating factors: Certain triggers, such as sleep deprivation, fever, trauma, or stress, can increase the likelihood of seizures in some children [2,4,7].
  • Description of the seizure: A detailed description of the seizure (e.g., focal or generalized) is crucial, including the child’s behavior, movements, and any changes in consciousness. Any evidence of partial (focal) onset, such as twitching or jerking on one side of the body, should also be noted [2]. It is also important to note if the child experienced incontinence during the seizure. It’s important to gather information about the postictal period including the length of the period, and any focal neurologic deficits, such as weakness or confusion, that may be present after the seizure. Also important is whether the child was able to easily fall back asleep after the seizure.
  • Current symptoms and vital signs: Assess the child’s current symptoms, vital signs, and whether they have recovered from the seizure or not.

2. Past Medical History:

  • Developmental and medical history: Information about the child’s developmental milestones and any previous medical conditions or treatments is important in identifying potential causes of seizures [6].
  • Immunization status: Some seizures are related to diseases that are preventable by vaccination, so it’s important to inquire about the child’s immunization history.
  • Previous seizures: This may indicate an underlying neurological condition or epilepsy. 
  • Previous treatment for seizures: Determine whether the child has received prior treatment for seizures, including medications, and if these treatments were effective [2].

3. Medication History:

  • Assess whether the child is taking any medications that can lower the seizure threshold or exacerbate seizures.

4. Family History:

  • A family history of seizures or other neurological disorders may suggest a genetic predisposition.

It is important to note that seizures may sometimes occur without a clear cause. The emergency department’s priority is stabilizing the patient and preventing further seizures or complications.

Several risk factors for pediatric seizures should be considered during medical history-taking. There may be a higher likelihood of seizures occurring in children who have a familial history of seizures or epilepsy. Children born prematurely or with a low birth weight may be at an increased risk of seizures because they are more likely to have brain injuries or developmental problems. Children with neurological disorders, such as cerebral palsy, or brain injuries, such as traumatic brain injury, may also be at an increased risk of seizures because these conditions can cause abnormal electrical activity in the brain. Metabolic disorders, such as hypoglycemia or hyponatremia, are also known risk factors. Certain infections, such as meningitis or encephalitis, can cause inflammation in the brain and are thus predisposing factors for pediatric seizures. Developmental disorders, such as autism or intellectual disability, have also been identified as risk factors for pediatric seizures. Having one or more of these risk factors does not necessarily mean that a child will develop seizures, but it is essential to be aware of them to detect seizures early and initiate appropriate treatment.

As with all medical emergencies, it is important to look out for red flags. Concerns should be raised if the seizure was delayed or related to a head injury. Developmental delay or regression should be ruled out. Bleeding disorders or anticoagulation therapy are important considerations during history-taking in cases of pediatric seizures. It is also critical to rule out CNS infections as a possible cause of the seizure. Red flags in the history may include fever, headache, photophobia, vomiting, bulging fontanelles, neck stiffness, decreased consciousness, and focal neurologic symptoms.

Physical Examination

A thorough physical examination is essential when evaluating a child with a suspected seizure. It aids in identifying underlying causes, associated conditions, and guiding further diagnostic and treatment decisions. The examination should be performed in conjunction with a detailed history and adapted to the child’s clinical condition and developmental stage [7,12]. Children with seizures may have developmental delays or regression, which can indicate an underlying problem.

Initial Assessment

  1. Stabilization: If the child is actively seizing, focus on stabilizing the airway, breathing, and circulation (ABC) and stopping the seizure [2,10,12].
  2. Vital Signs [2,5,7]:
    • Temperature: Identify fever (above 38°C/100.4°F), the most common cause of seizures in children.
    • Heart Rate and Blood Pressure: Monitor for abnormalities that may indicate underlying conditions or complications.
    • Oxygen Saturation: Ensure adequate oxygenation.

General Appearance

  1. Level of Consciousness: Assess alertness and orientation. Note any altered mental status, which may suggest ongoing issues like status epilepticus or other underlying conditions [4,10].
  2. Activity Level and Responsiveness: Observe for irritability, excessive sleepiness, or signs of distress. Are they irritable? Are they playful? Are they well-kept? Look for signs of neglect or child abuse.
  3. Dysmorphic Features: Look for unusual physical features that may suggest a genetic or developmental syndrome [2].

Head and Neck Examination

  1. Head Circumference: Measure head size, especially in infants, as microcephaly can indicate an underlying condition [2,6].
  2. Signs of Trauma: Check for bruising or swelling that may suggest head injury.
  3. Fontanelles: In infants, examine the anterior fontanelle for bulging, which may indicate increased intracranial pressure.
  4. VP Shunt: Assess for ventriculoperitoneal (VP) shunt placement and any signs of malfunction or infection [2].
  5. Meningeal Signs: Look for nuchal rigidity or other signs of meningeal irritation, suggesting CNS infection [12].
  6. Eye and ear examination: Changes in pupils, papilledema, and retinal hemorrhages, or abnormal movements of the eyes that can indicate brain injury. Bulging tympanic membranes can indicate otitis media.

Skin Examination

  1. Bruising: Identify unexplained bruising, which may point to bleeding disorders or child abuse.
  2. Skin Rashes: Look for signs such as café au lait spots (indicative of neurofibromatosis), adenoma sebaceum or ash leaf spots (associated with tuberous sclerosis) [6], and port wine stains (typical of Sturge-Weber syndrome).
  3. Neurocutaneous Markers: Use a Woods lamp to detect signs of neurocutaneous syndromes.

Cardiovascular and Abdominal Examination

  1. Heart Sounds: Listen for abnormalities that may indicate a cardiac issue. Heart murmurs or arrhythmias that may be related to seizures.
  2. Abdomen: Palpate for masses or organomegaly, which may suggest a metabolic disorder. Children with metabolic disorders, such as liver or kidney disease, may have an enlarged liver or spleen, which can contribute to seizures.

Neurological Examination [2,4,12]

  1. Mental Status: Evaluate consciousness, orientation, and behavior.
  2. Cranial Nerves: Check pupillary responses, eye movements, and facial symmetry.
  3. Motor Function: Assess muscle strength, tone, symmetry, and any abnormal movements. Look for Todd’s paresis or focal weakness post-seizure.
  4. Reflexes: Evaluate deep tendon reflexes, noting asymmetry.
  5. Meningeal signs: Brudzinski’s or Kernig’s sign. Neck stiffness should also be assessed.
  6. Sensory Function: Test sensory responses, noting any deficits.
  7. Gait and Coordination: Observe gait, coordination, and balance in age-appropriate children.

Postictal Examination [6]

  1. Neurological Status: Note persistent confusion, weakness, or other deficits during the postictal phase, which may help localize the seizure origin.
  2. Symmetry: Pay close attention to symmetrical muscle tone, reflexes, and movements to identify potential focal brain issues.

Important Considerations

  1. Age-Appropriate Assessment: Adjust the neurological exam based on the child’s developmental stage, as young children may not fully cooperate [6].
  2. Clinical Context: Always interpret findings within the context of the child’s history and other clinical information [12].

Alternative Diagnoses

It is important to distinguish between true seizures and seizure mimics in the pediatric population, as the causes, treatment options, and outcomes can be quite different [14,15]. Examples of seizure mimics include vasovagal syncope, breath-holding spells, reflex anoxic seizures, arrhythmias, and non-epileptic paroxysmal events. It is helpful to look for clues in the history to rule out such mimics. A vagal reflex can be precipitated by a sudden fright or minor trauma. Temper tantrums should prompt consideration of breath-holding spells, which can lead to hypoxia and, in turn, a short tonic-clonic event with a quick recovery time. Visual and auditory changes paired with lightheadedness are suggestive of a vasovagal attack. A history of palpitations or strenuous exercise just before the event could indicate arrhythmias.

Certain symptoms can indicate a genuine seizure [14,15], including but not limited to:

  • Biting of the tongue on one side (high specificity).
  • Swift blinking of the eyes.
  • Fixed gaze with dilated pupils.
  • Repetitive lip movements.
  • Elevated heart rate and blood pressure during the episode.
  • A post-seizure phase.

Fevers are the most common cause of seizures in children [16]. Febrile convulsions can be further categorized into simple or complex febrile seizures:

  • Simple febrile seizures are generalized, last less than 15 minutes, and occur only once within a 24-hour timeframe. They are typically not associated with neurological deficits or other significant findings.
  • Complex febrile seizures last longer than 15 minutes, are focal (involving only one part of the body), or occur multiple times within a 24-hour period. While both types of febrile seizures are generally benign, complex febrile seizures require further investigation to rule out organic causes and carry a slightly higher risk of developing into epilepsy or other neurological disorders later in life.

In an afebrile child presenting with seizures, the differential diagnoses are extensive. Possible causes include:

  • Structural abnormalities in the brain, such as tumors, cysts, or malformations [16].
  • Metabolic disturbances, such as hypoglycemia, electrolyte imbalances, or trauma.

Status epilepticus is a medical emergency, defined as a seizure lasting longer than 5 minutes or recurrent seizures without regaining consciousness in between [16]. It can occur in both children and neonates and is associated with significant morbidity and mortality. Non-convulsive status epilepticus should be considered in any child with an altered mental status; it is ill-defined and remains a diagnosis of exclusion.

Neonatal seizures can be caused by a variety of factors, including hypoxic-ischemic encephalopathy, metabolic disturbances, infections, and intracranial hemorrhage [16]. Neonatal seizures can have serious consequences if left untreated, including brain damage and developmental delays.

Acing Diagnostic Testing

A bedside blood glucose level should be obtained as soon as possible to rule out hypoglycemia [4,15,17]. Venous blood gas, magnesium, and phosphorus levels are also valuable investigations to assess other electrolyte imbalances [12]. When there is concern for metabolic or respiratory disturbance, an arterial blood gas test may be considered [10]. Basic laboratory tests, including CBC, CRP, urine and blood cultures, are indicated when there is suspicion of underlying infections [2,4]. Beta HCG levels may be measured in pediatric seizures because a rare cause of seizures in children is a brain tumor called a germinoma, which secretes beta HCG. Beta HCG can be detected in blood or cerebrospinal fluid (CSF) to help confirm the diagnosis. Ammonia, Lactate, Pyruvate, if an inborn error of metabolism is suspected, these tests may be performed [2]. Antiepileptic drug  levels should be measured in children with known seizure disorders to ensure they are receiving an appropriate dose. Under-dosing can result in continued seizures, while overdosing can lead to side effects such as drowsiness, nausea, or confusion. A toxicology screen may be ordered if there is a concern for drug or alcohol use [12].

Imaging studies such as CT or MRI should be considered for children with focal seizures, persistent seizures despite acute management, or seizures in children under six months of age [4,6]. Signs of elevated intracranial pressure (ICP) also warrant imaging, especially in the context of a history of bleeding disorders or anticoagulant use. Although MRI provides superior anatomic detail, it often requires sedation, which can interfere with the patient’s assessment, making CT the preferred initial imaging study.

Lumbar puncture is recommended for infants aged 6 to 12 months who have not received adequate vaccination against H. influenzae or Streptococcus pneumoniae, or whose vaccination status is unknown, as these bacteria are common causes of bacterial meningitis in this age group [6]. Additionally, lumbar puncture should be considered in infants receiving active antibiotic therapy, as antibiotics can mask meningeal signs. Infants with focal or prolonged seizures, abnormal neurological examinations, or toxic appearance are high-risk groups in which lumbar puncture is strongly advised.

 

An electroencephalogram (EEG) is a non-invasive test that measures electrical activity in the brain and is crucial for identifying seizure activity and epileptiform discharges [5,6,18]. It aids in classifying seizure disorders, such as generalized or partial seizures, and can detect specific patterns associated with particular epilepsy syndromes [18]. Ideally, an EEG should be performed within 24 hours of the seizure to maximize its diagnostic utility [6].

Risk Stratification

The range of potential causes for non-febrile seizures in pediatric patients is broad, including metabolic imbalances, mass lesions, and non-accidental trauma. One specific diagnosis that is relatively common in children under 6 months of age and easily detectable to prevent extensive invasive testing is hyponatremia caused by formula over-dilution. In the emergency department, 3 ml/kg of 3% hypertonic saline is the mainstay of therapy.

A first febrile seizure is concerning and requires prompt evaluation and management [16]. It may be a sign of an underlying medical condition. Some factors increase the risk of bacterial infection, such as age less than 6 months or more than 60 months with the first febrile seizure, or age less than 12 months with incomplete or unknown immunization history. In addition, a first febrile seizure in a clinically unwell child with symptoms of infection, meningeal signs, or dehydration may indicate a more serious underlying condition and requires urgent medical attention.

Febrile status epilepticus, which is a prolonged seizure lasting more than 30 minutes or a series of seizures without full recovery between them, is another potential complication that can occur in the context of a febrile illness. It is important to recognize the signs and symptoms of febrile status epilepticus, such as a fever, stiff neck, or convulsions, and seek immediate medical attention to prevent serious neurological damage.

Management

The management of pediatric seizures in the emergency department primarily focuses on stabilizing the patient, treating the underlying cause, and preventing further seizures or complications [16,19]. The initial management of an actively seizing child includes ensuring that the child’s airway is protected and providing adequate oxygen and circulatory support. Oxygen can be supplied via a nasal cannula or simple face mask, and preparations for endotracheal intubation should be made if airway management requires escalation. The next step is to assess vital signs and check blood glucose levels to rule out hypoglycemia. Intravenous (IV) or intraosseous (IO) access should be established promptly, and the patient should be connected to a monitor by this stage. In febrile seizures, antipyretic therapy is the mainstay of treatment to relieve symptoms and is usually sufficient. Seizures lasting 15 minutes or longer should be managed in accordance with status epilepticus protocols, with the goal of rapidly stopping the seizure using antiepileptic medications to prevent permanent neuronal injury.

A seizure lasting 5 minutes is highly likely to be prolonged; thus, most protocols use a 5-minute definition. Initial management includes maintaining airway, breathing, and circulation (ABCs), administering oxygen, and preparing for intubation if required [16,19]. Hypoglycemia, defined as a capillary blood glucose (CBG) level of less than 60 mg%, should be corrected with a bolus of IV 10% dextrose at 5 mL/kg; this can be repeated to normalize serum glucose levels. IV or IO access should be secured, and blood samples should be sent for investigations. Benzodiazepines are the first-line antiepileptic agents. Options include intramuscular (IM) Midazolam (10 mg for patients >40 kg; 5 mg for patients 13–40 kg), IV Lorazepam (0.1 mg/kg/dose, maximum 4 mg/dose; can be repeated once), or IV Diazepam (0.15–0.2 mg/kg/dose, maximum 10 mg/dose; can be repeated once). If these are not feasible, IV Phenobarbital (15 mg/kg/dose as a single dose), rectal Diazepam (0.2–0.5 mg/kg, maximum 10 mg/dose; can be repeated once), or intranasal/buccal Midazolam may be used.

If first-line therapy is unsuccessful, second-line agents should be administered. Options include IV Fosphenytoin (20 mg PE/kg, maximum 1,500 mg PE/dose as a single dose), IV Valproic Acid (40 mg/kg, maximum 3,000 mg/dose as a single dose), or IV Levetiracetam (60 mg/kg, maximum 4,500 mg/dose as a single dose). IV Phenobarbital (15 mg/kg as a single dose) is another option if other agents are not appropriate. If first- and second-line therapies fail, anesthetic doses of Thiopental, Midazolam, Phenobarbital, or Propofol can be administered. This requires continuous EEG monitoring.

If the patient responds to any of these agents and returns to baseline, symptomatic medical therapy should be initiated. Management of non-convulsive status epilepticus follows a similar approach to that of convulsive status epilepticus. (Figure 1) [20]

Figure 1 - Interventions and management of SE in the ED and inpatient setting [2]. (SEHA pediatric seizure algorithm. Permission granted by Dr. Thiagarajan Jaiganesh)

In neonates, the same stabilization principles apply, including maintaining ABCs, collecting blood samples, and checking and correcting electrolytes [16]. IV Phenobarbitone (20 mg/kg) is administered as the first-line antiepileptic; this can be repeated in 5 mg/kg boluses every 15 minutes (maximum dose of 40 mg/kg) until the seizure is aborted. If the seizure persists, IV Phenytoin (15–20 mg/kg), diluted in equal parts with normal saline, should be administered at a maximum rate of 1 mg/kg/min over 35–40 minutes.

If the seizure remains unresolved, IV Lorazepam (0.05–0.1 mg/kg) or Diazepam (0.25 mg/kg bolus or 0.5 mg/kg rectal) may be used. Alternatively, IV Midazolam can be administered as a continuous infusion; this involves an initial IV bolus of 0.15 mg/kg followed by a continuous infusion starting at 1 μg/kg/min, increasing by 0.5–1 μg/kg/min every 2 minutes (maximum 18 μg/kg/min). Lastly, if all else fails, 100 mg IV or oral Pyridoxine may be administered. This is particularly useful for treating Pyridoxine-dependent neonatal seizures or seizures caused by Isoniazid (INH) toxicity. (Figure 2) [21].

Figure 2 - Neonatal seizure algorithm [21] - Open access https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8857130/figure/Fig2/

When To Admit This Patient

In most cases, hospitalization is not necessary after a first unprovoked seizure, provided that a neurological examination is normal and prompt follow-up evaluation can be arranged [13]. Consultation with a neurologist and electroencephalography (EEG) can typically be performed on an outpatient basis. However, children who have experienced a prolonged seizure or who do not return to their baseline state within a few hours should be admitted to the hospital.

Hospitalization should also be considered in cases of extreme parental anxiety or if adequate follow-up evaluation cannot be arranged. It is essential to counsel parents about the increased likelihood of recurrence, which is approximately 33% overall. The risk of recurrence is higher in children under 18 months of age, when the temperature during the first convulsion is below 40°C, when the first seizure occurs within an hour of the onset of fever, or if there is a family history of febrile seizures.

Revisiting Your Patient

The image was produced by using ideogram 2.0.

Our patient was immediately moved to the resuscitation unit, placed on a simple face mask, and connected to monitors. She was administered rectal Diazepam; however, the seizure did not resolve. By this time, intraosseous (IO) access was established, and 0.1 mg/kg of Lorazepam (same as the IV dose) was given. This successfully aborted the seizure.

At this point, her vitals were as follows: temperature (T) 40°C, heart rate (HR) 93, respiratory rate (RR) 29, and blood pressure (BP) 118/90. She was lethargic and responsive only to painful stimuli. Other notable findings on examination included a full and tense anterior fontanelle, questionable neck rigidity, red and bulging tympanic membranes, reactive but unfocused pupils, a normal heart, lungs, and abdomen, good color and perfusion, and no petechiae or rashes. The patient displayed weak movement in all limbs and hyperactive deep tendon reflexes.

Pediatrics was consulted, and a presumptive diagnosis of meningitis was made. A complete blood count (CBC), C-reactive protein (CRP), blood culture, and chemistry panel were drawn. IV access was established at this point. Since increased intracranial pressure (ICP) was suspected, a lumbar puncture (LP) was initially deferred, and she was immediately given 500 mg of IV Ceftriaxone. A stat CT scan of the brain was normal, so an LP was performed, revealing visibly turbid cerebrospinal fluid (CSF).

The CSF analysis showed a white blood cell (WBC) count greater than 1000 cells/μL, with 95% neutrophils and 5% monocytes, a total protein level of 75 mg/dL, and a glucose level of 25 mg/dL. A Gram stain of the CSF revealed numerous WBCs and a few gram-positive cocci. She was admitted to the pediatric intensive care unit (PICU) for further management.

Authors

Picture of Neema Francis

Neema Francis

Dr. Neema Francis was born and raised in Dubai, UAE. She is currently a fourth-year emergency medicine resident at Tawam Hospital. She graduated with an MBBS from Gulf Medical University in 2020 and completed her internship at Sheikh Shakbout Medical City in 2021. Dr. Francis has a passion for volunteering and has been involved in various healthcare initiatives. She is also a competent researcher with publications to her name and a keen interest in emergency medicine and pediatric emergency medicine.

Picture of Faiz Ahmad

Faiz Ahmad

Picture of Thiagarajan Jaiganesh

Thiagarajan Jaiganesh

Dr. Jaiganesh is a Chairman and Consultant in Adult and Pediatric Emergency Medicine and serves as an Adjunct Assistant Professor at UAE University. As the former Director of the Emergency Medicine Residency Program at Tawam Hospital in Al Ain, UAE, Dr. Jaiganesh is dedicated to training the next generation of emergency medicine professionals. With a strong academic and professional background, Dr. Jaiganesh has published numerous peer-reviewed articles on emergency medicine and contributes as a Section Editor and Chapter Author for notable medical texts, including the Oxford Handbook for Medical School. A sought-after speaker, Dr. Jaiganesh has been invited to present at numerous national and international conferences and serves as an instructor in various life support courses. Additionally, Dr. Jaiganesh is an expert in medico-legal and clinical negligence matters, providing valuable insights into complex legal and ethical cases in healthcare.

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References

  1. Glauser T, Ben-Menachem E, Bourgeois B, et al. Updated ILAE evidence review of antiepileptic drug efficacy and effectiveness as initial monotherapy for epileptic seizures and syndromes. Epilepsia. 2013;54(3):551-563. doi:10.1111/epi.12074.
  2. Friedman MJ, Sharieff GQ. Seizures in children. Pediatr Clin North Am. 2006;53(2):257-277. doi:10.1016/j.pcl.2005.09.010.
  3. Kazemi H, Rahmati M, Soltani Z, Kazemi A. Association of epilepsy and migraine headache. J Clin Med. 2019;8(1):39. doi:10.3390/jcm8010039.
  4. Chen CY, Chang YJ, Wu HP. New-onset seizures in pediatric emergency. Pediatr Neonatol. 2010;51(2):103-111. doi:10.1016/S1875-9572(10)60019-8.
  5. El-Radhi AS. Management of seizures in children. Br J Nurs. 2015;24(3):152-155. doi:10.12968/bjon.2015.24.3.152.
  6. Fine A, Wirrell EC. Seizures in children. Pediatr Rev. 2020;41(7):321-347. doi:10.1542/pir.2019-0134.
  7. Sidhu R, Velayudam K, Barnes G. Pediatric seizures. Pediatr Rev. 2013;34(8):333-342. doi:10.1542/pir.34-8-333.
  8. Lambert MV, Robertson MM. Depression in epilepsy: etiology, phenomenology, and treatment. Epilepsia. 2002;43(Suppl 2):21-27. doi:10.1046/j.1528-1157.43.s.2.3.x.
  9. Krawiec C, Muzio MR. Neonatal Seizure. In: StatPearls. Treasure Island (FL): StatPearls Publishing; January 2, 2023.
  10. Lawton B, Deuble N. Seizures in the paediatric emergency department. J Paediatr Child Health. 2016;52(2):147-150. doi:10.1111/jpc.12979.
  11. Wirrell EC, Grossardt BR, Wong-Kisiel LC, Nickels KC. Incidence and classification of new-onset epilepsy and epilepsy syndromes in children in Olmsted County, Minnesota from 1980 to 2004: A population-based study. Epilepsy Res. 2011;95(1-2):110-118. doi:10.1016/j.eplepsyres.2011.03.017.
  12. Adams SM, Knowles PD. Evaluation of a first seizure. Am Fam Physician. 2007;75(9):1342-1347.
  13. Helman A. Emergency management of pediatric seizures. Emergency Medicine Cases. December 1, 2015. Accessed January 17, 2023. https://emergencymedicinecases.com/emergency-management-of-pediatric-seizures/
  14. Mayo Clinic. Seizures – Symptoms and causes. Mayo Clinic. February 24, 2021. Accessed January 17, 2023. https://www.mayoclinic.org/diseases-conditions/seizure/symptoms-causes/syc-20365711
  15. Wilfong A. Seizures and epilepsy in children: clinical and laboratory diagnosis. In: UpToDate. February 12, 2022. Accessed January 17, 2023. https://www.uptodate.com/contents/seizures-and-epilepsy-in-children-clinical-and-laboratory-diagnosis
  16. Richhariya D. Signs and Symptoms in Clinical Practice. Jaypee Brothers Medical Publishers; 2020:152-161.
  17. Helman A. EM Cases: Emergency management of pediatric seizures. emDOCs.net – Emergency Medicine Education. July 14, 2017. Accessed January 17, 2023. http://www.emdocs.net/em-cases-emergency-management-pediatric-seizures/
  18. Tharp BR. An overview of pediatric seizure disorders and epileptic syndromes. Epilepsia. 1987;28(Suppl 1):S36-S45. doi:10.1111/j.1528-1157.1987.tb05755.x.
  19. Friedman J. Emergency management of the pediatric patient with generalized convulsive status epilepticus. Paediatr Child Health. 2011;16(2):91-104. doi:10.1093/pch/16.2.91.
  20. Al-Hashaykeh NO, et al. Pediatric Status Epilepticus Clinical Practice Guideline. SEHA Pediatric Critical Care Council; 2023.
  21. Vegda H, Krishnan V, Variane G, Bagayi V, Ivain P, Pressler RM. Neonatal seizures—perspective in low-and middle-income countries. Indian J Pediatr. 2022;89(3):245-253. doi:10.1007/s12098-021-04039-2.

Reviewed and Edited By

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

The Limping Child (2024)

~ iEM Education Project Team ~ Leave a comment

by Elizabeth Zorovich, Vincent Gonzalez, & Vlad Panaitescu

 

Authors
Listen

You Have A New Patient!

A four-year-old boy presents to the emergency department with his mother. The mother states that the patient has been limping and complaining of pain in his right leg for the past two days. She also reports that the right hip is red and painful to touch. The patient refuses to walk or move his right hip during triage. The mother states that the patient’s head felt warm this morning when he woke up, but she did not take his temperature before arriving. Both the mother and patient deny any falls or known injuries.

The image was produced by using ideogram 2.0.

Vital signs are as follows: temperature 40°C, heart rate 130 beats per minute, blood pressure 100/70 mmHg, respiratory rate 16 breaths per minute, SpO₂ 98% on room air, and weight 16 kg. The patient is up to date on vaccinations.

What Do You Need To Know?

Importance

Limping in children is a common symptom encountered in the emergency department, necessitating careful evaluation due to its wide range of potential causes. While it may originate from benign conditions like sprains, it can also indicate serious underlying issues such as malignancies or infections, which can be life-threatening if not promptly diagnosed [1]. A thorough assessment, containing a detailed history and physical examination, is crucial for establishing the correct diagnosis [2]. This process can be particularly challenging depending on the child’s age, as younger patients may struggle to articulate their symptoms effectively. Therefore, proper history-taking and examination skills are essential, and primary caregivers often provide invaluable insights that can guide the clinician in identifying the root cause of the limping [3]. Prompt recognition and appropriate management of the underlying condition are vital to ensure optimal outcomes for the pediatric patient.

Epidemiology

The epidemiology of limping in children is an important area of study, although literature on this topic remains limited. According to studies [4,5], approximately four percent of pediatric visits to emergency departments are attributed to gait disturbances, highlighting the prevalence of this issue in clinical settings. Limping is a multifactorial symptom that can arise from various underlying conditions, including trauma, infections, and developmental disorders. The high percentage of emergency visits highlights the need for careful evaluation and management of limping in children, particularly in the context of acute injuries or infections.

Research indicates that limping is notably more prevalent in males than females, with a median age of four years for affected children [6,7]. This gender disparity may be linked to differences in activity levels and risk-taking behaviors among young boys, who are often more physically active than their female counterparts. The developmental stage of toddlers also plays a significant role in the incidence of limping. Due to their active nature and immature gait patterns, toddlers frequently experience accidental falls, which can lead to temporary limping. Additionally, during this stage of development, children are more susceptible to infections, particularly osteomyelitis, as their bony cortex is still maturing and offers less resistance to bacterial invasion [8].

As children transition into school age, their increased mobility and adventurous spirit contribute to a higher risk of traumatic injuries, further elevating the incidence of limping in this demographic. Activities such as jumping off objects or engaging in sports can result in strains, sprains, or fractures, all of which may manifest as a limp [9].

Pathophysiology

Limping in children is a multifaceted clinical symptom that can arise from various underlying pathophysiological processes. The assessment of a limp must take into account the developmental status of the child, as a proper diagnosis cannot be made until the child is able to stand, typically around nine months of age. The average onset of independent walking occurs between twelve and eighteen months, during which a child’s gait transitions from a broad-based stance to a more refined adult-like gait by the age of three [10, 11]. This developmental progression is crucial, as the normal gait cycle involves intricate coordination between the nervous and musculoskeletal systems, comprising two main phases: the stance phase and the swing phase. The stance phase encompasses the period from heel strike to toe-off, while the swing phase involves a sequence of hip flexion, knee flexion, foot dorsiflexion, and knee extension, which must function harmoniously to maintain a fluid gait [12].

A limp is defined as a deviation from normal age-appropriate gait patterns and can be categorized into three primary types: antalgic, Trendelenburg, and short leg gait. An antalgic gait, often referred to as a “quick step,” is characterized by a shortened stance phase on the affected limb, typically due to pain. This type of gait can result from various causes, including traumatic injuries, malignancies, or infectious processes [13]. Conversely, the Trendelenburg gait is marked by a drop of the affected hip during the swing phase of the contralateral leg, accompanied by a tilt of the pelvis towards the affected side when standing. This gait pattern is primarily indicative of musculoskeletal weakness and may be observed in conditions such as Legg-Calvé-Perthes disease (LCPD), slipped capital femoral epiphysis (SCFE), developmental dysplasia of the hip, and certain neuromuscular disorders [14]. Lastly, a short leg gait arises from a limb length discrepancy, which can be attributed to improper healing of fractures, osteomyelitis, bone tumors, or bone cysts [15].

Medical History

The evaluation of a limping child in the emergency department necessitates a comprehensive and systematic approach to history taking, as the potential causes of a limp can vary widely, ranging from benign to serious conditions. The initial step involves understanding the chief complaint by gathering detailed information regarding the onset, duration, and progression of the limp. It is crucial to ascertain whether the limp is acute, chronic, or recurrent, and to identify any inciting events, such as trauma or infection, that may have preceded its onset [16]. This foundational information is vital in narrowing down the differential diagnosis and determining the urgency of the situation.

In addition to the chief complaint, the past medical history plays a pivotal role in identifying underlying factors that could predispose a child to limping. Relevant systemic illnesses, previous injuries, or musculoskeletal disorders must be considered, as these can indicate possible orthopedic or systemic causes of the limp [17]. For younger children, a thorough birth history is essential to rule out perinatal factors such as developmental dysplasia of the hip, birth trauma, or neuromuscular disorders that could manifest as limping [18]. Furthermore, it is important to assess any known allergies, as this information can influence the choice of diagnostic imaging or therapeutic interventions.

Evaluating the child’s recent intake and output is another critical aspect of history taking, as it can reveal signs of systemic illness such as dehydration or febrile illnesses. Conditions like transient synovitis or septic arthritis may present with a limp, and understanding the child’s hydration status can provide valuable insights into their overall health [19]. Additionally, vaccination history is paramount, as it helps exclude infections caused by vaccine-preventable pathogens, including osteomyelitis from Haemophilus influenzae type B [20].

Finally, gathering information about family history, especially concerning musculoskeletal or genetic conditions, along with social history factors such as daycare attendance, can further inform the clinician’s assessment. Increased exposure to infections in daycare settings may raise the likelihood of conditions that cause limping [21]. A meticulous history-taking process lays the groundwork for formulating a differential diagnosis, which is crucial for guiding further examination and investigations in the emergency department.

Physical Examination

The evaluation of limping children in the emergency department requires a comprehensive physical examination, as the underlying causes can range from benign to serious conditions. A thorough examination should begin with a bilateral joint assessment to ensure a comparative analysis. Each joint must be evaluated for overlying skin changes, deformities, and the presence of palpable pulses. Additionally, both active and passive ranges of motion should be meticulously assessed [22]. This thorough examination allows clinicians to identify any abnormalities that could indicate conditions such as septic arthritis or osteomyelitis, which may require urgent intervention.

In cases where the child can localize pain, it is crucial to examine the joints above and below the area of concern. This approach can help in identifying referred pain or issues that may not be immediately apparent [23]. Following the joint examination, observing the child’s gait is essential. An unassisted gait should be observed first; if the child is unable to walk independently, an assisted gait evaluation should be conducted. This observation helps in determining the side of the limp and the type of limp present, which can provide valuable clues regarding the underlying etiology [24]. For instance, a trendelenburg gait may suggest hip pathology, while a toe-walking gait could indicate issues related to the Achilles tendon or neurological conditions.

Subsequently, a full neurological examination should be performed, encompassing the assessment of reflexes, sensation, and cranial nerve function. This step is vital, as neurological deficits may point towards serious underlying conditions such as spinal cord compression or central nervous system infections [25]. Clinicians should remain vigilant for red flag signs, including fever, tachycardia, inability to ambulate independently, skin changes, and decreased range of motion of a joint, as these may indicate serious conditions requiring immediate attention [26].

Alternative Diagnoses

Acute septic arthritis, osteomyelitis, and malignancy should be the primary concerns to rule out in any child presenting with a limp.

Acute septic arthritis is an infection in a joint and the surrounding synovial fluid. Septic arthritis is most often a hematogenous infection that seeds from any site of trauma or infection. This condition occurs more frequently in children than in adults. The sluggish blood flow in the metaphyseal capillaries and immature bony cortices of children makes them more susceptible. The most commonly affected locations in the body are the large joints of the lower limb, including the hip, knee, and ankle. Staphylococcus aureus and respiratory pathogens are the most common causative agents [27].

Osteomyelitis is an infection of the bone. Staphylococcus aureus is the most common cause of osteomyelitis regardless of age. During the neonatal period, group B streptococcus is the second most common causative bacterium. Hematogenous spread accounts for more than fifty percent of cases. Osteomyelitis and acute septic arthritis may occur simultaneously [28].

Malignancy can be a cause of musculoskeletal pain and limping in pediatric patients. The most common malignant pediatric bone tumors are osteogenic sarcoma and Ewing’s sarcoma. Pain from bone tumors may be acute or chronic, with acute pain often related to a pathological fracture.

Other causes of pediatric limps span a wide range of medical conditions categorized into trauma, inflammatory, developmental, neurologic, metabolic, and hematologic origins. Trauma is a common cause and may result from fractures, stress fractures, or soft tissue injuries. Inflammatory conditions include transient synovitis and reactive arthritis, which are significant contributors to limping in children. Developmental issues such as dysplasia of the hip, slipped capital femoral epiphysis (SCFE), and limb length discrepancies also play a role. Neurologic causes include muscular dystrophy and peripheral neuropathy, which affect the musculoskeletal system’s normal functioning. Metabolic conditions like rickets and hyperparathyroidism can weaken bones, leading to limping, while hematologic disorders such as sickle cell disease and hemophilia may cause joint or bone pain, further complicating mobility. Recognizing these varied etiologies is crucial for accurate diagnosis and effective management.

In the emergency department, differentiating between septic arthritis, osteomyelitis, and transient synovitis in limping children is critical due to the varying urgency of their management. Septic arthritis and osteomyelitis are both serious bacterial infections that require prompt intervention to prevent long-term complications, while transient synovitis is a self-limiting condition that typically follows a viral upper respiratory infection and is managed conservatively with analgesia and rest [29]. The clinical presentation of these conditions can overlap significantly, including symptoms such as joint pain, swelling, and decreased mobility, which complicates the diagnostic process [30].

To effectively differentiate septic arthritis from transient synovitis, clinicians can employ the Kocher criteria, a validated clinical tool specifically designed for pediatric patients. This scoring system assesses four key factors: inability to bear weight on the affected limb, an erythrocyte sedimentation rate (ESR) greater than 40 mm/hr, the presence of fever, and a white blood cell (WBC) count exceeding 12,000 [31]. The probability of septic arthritis increases with the number of positive criteria; when all four are present, the risk of septic arthritis rises to 99%. Conversely, the probability is significantly lower with fewer positive criteria, dropping to 3% with only one criterion met [31]. This stratification aids clinicians in determining the need for further diagnostic testing, such as joint aspiration or imaging studies, to confirm the diagnosis and initiate appropriate treatment.

Osteomyelitis, another potential diagnosis in limping children, can also present with similar symptoms but typically involves the bone rather than the joint. It may occur concurrently with septic arthritis or as a separate entity, and it often requires a combination of clinical evaluation, laboratory tests, and imaging studies for accurate diagnosis [32]. The distinction between these conditions is vital because while both septic arthritis and osteomyelitis necessitate urgent antibiotic therapy and possibly surgical intervention, transient synovitis can be managed with conservative measures, reducing the risk of unnecessary invasive procedures [30].

Acing Diagnostic Testing

Laboratory Tests

When evaluating limping children in the emergency department, laboratory tests play a crucial role in diagnosing underlying conditions, such as infections or malignancies. A complete blood count (CBC) is often the first step in this diagnostic process. The CBC can help identify leukocytosis, which may suggest an infectious process, or anemia that could indicate chronic disease or malignancy [33]. In addition to the CBC, acute-phase reactants, such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), should be ordered to assess for inflammation. Elevated levels of these markers can indicate an inflammatory process, which is particularly important in differentiating between benign causes of limping and more serious conditions like osteomyelitis or malignancy [34].

In cases where the child presents with fever, it is essential to obtain blood cultures, as they can provide critical information regarding systemic infections. Blood cultures should ideally be collected before the initiation of antibiotics to increase the likelihood of identifying any pathogens present in the bloodstream [35]. This is particularly vital in children who may have septic arthritis, a serious condition that requires prompt diagnosis and treatment. If septic arthritis is suspected, joint aspiration is often performed to analyze synovial fluid. The synovial fluid should be sent to the laboratory for comprehensive analysis, including cell counts, inflammatory markers, and bacterial cultures. Elevated white blood cell counts in the synovial fluid, particularly with a predominance of neutrophils, can support a diagnosis of septic arthritis [36]. Furthermore, bacterial cultures can help identify the causative organism, guiding appropriate antibiotic therapy.

Imaging

Imaging plays a crucial role in the evaluation of limping children in the emergency department, as it aids in diagnosing various underlying conditions. X-rays are often the first line of imaging in pediatric patients presenting with a limp. They are effective in assessing for bone damage, fractures, and certain signs of trauma or malignancy [37]. However, it is important to note that while X-rays can provide valuable information, they may not always reveal the full extent of a condition. For instance, in cases of acute septic arthritis and acute osteomyelitis, the initial X-ray may appear normal despite the presence of significant pathology [38]. This limitation underscores the importance of considering additional imaging modalities when clinical suspicion remains high.

Magnetic Resonance Imaging (MRI) is particularly useful in further evaluating suspected cases of osteomyelitis. MRI offers superior soft tissue contrast and can identify early changes in bone marrow that may not be visible on X-rays [39]. This imaging modality is non-invasive and provides a comprehensive view of both the bony structures and surrounding soft tissues, making it an invaluable tool in complex cases where osteomyelitis is a concern. Additionally, MRI can help differentiate osteomyelitis from other conditions such as tumors or trauma, guiding appropriate management strategies.

Ultrasound is another beneficial imaging modality in the emergency setting, especially for evaluating joint effusions. It can be performed at the bedside, allowing for rapid assessment and intervention [40]. Unlike X-rays and MRIs, ultrasound does not involve radiation exposure, making it particularly suitable for pediatric patients. This imaging technique can assist in determining the need for further procedures, such as aspiration or drainage of a joint effusion, thereby facilitating timely treatment.

A line drawn along the lateral margin of the left femoral metaphysis does not intersect the epiphysis on the AP view (Klein's line), consistent with findings of a slipped upper femoral epiphysis. The right side shows normal alignment. - Source: Gaillard F Slipped upper femoral epiphysis. Case study, Radiopaedia.org (Accessed on 30 Dec 2024) https://doi.org/10.53347/rID-7688
The green line on the normal represents the line of Klein drawn on the superior edge of the femoral neck intersecting the lateral aspect of the superior femoral epiphysis. - Source: Murphy A Slipped capital femoral epiphysis (illustrations). Case study, Radiopaedia.org (Accessed on 30 Dec 2024) https://doi.org/10.53347/rID-181107
Moderate effusion with tiny echoes is observed in the anterior synovial recess of the left hip joint. There is no evidence of synovial hypervascularity, cortical erosion of the underlying femur, or periarticular collection. - Source: Patel M Hip septic arthritis (paediatric). Case study, Radiopaedia.org (Accessed on 30 Dec 2024) https://doi.org/10.53347/rID-77571
The right femoral epiphysis shows irregularity and abnormal marrow signals, with low signal on T1 and bright signal on STIR/T2 FATSAT, indicating marrow edema. There is loss of joint space at the top of the right hip joint and moderate joint effusion. Diagnosis: Septic arthritis of the right hip joint. - Source: Abdrabou A Septic arthritis of the hip joint. Case study, Radiopaedia.org (Accessed on 30 Dec 2024) https://doi.org/10.53347/rID-27744
Group A: crescent sign involves 1/2 of femoral head. Source: Benoudina S Legg-Calve-Perthes disease: Salter-Thompson classification. Case study, Radiopaedia.org (Accessed on 30 Dec 2024) https://doi.org/10.53347/rID-44064
There is widening and flattening of the femoral head with early signs of fragmentation. The femoral neck appears widened, and there is sclerosis with an irregular articular surface of the left acetabulum. - Source: Sargent M Perthes disease with coxa magna. Case study, Radiopaedia.org (Accessed on 30 Dec 2024) https://doi.org/10.53347/rID-5978

Risk Stratification

Risk stratification in limping children presenting to the emergency department is a crucial process that aids in identifying serious underlying conditions and prioritizing care based on the urgency and severity of potential diagnoses. The initial assessment begins with evaluating the child’s symptoms and vital signs. For instance, the presence of fever, tachycardia, or hypotension may indicate systemic infections, such as septic arthritis or osteomyelitis, necessitating immediate intervention [41]. Additionally, an acute, non-weight-bearing limp, especially following trauma, raises the suspicion for fractures, dislocations, or soft tissue injuries, while chronic or insidious symptoms may point towards more serious conditions like malignancies, juvenile idiopathic arthritis, or developmental disorders [42].

Age plays a pivotal role in refining the differential diagnosis in limping children. Toddlers are particularly vulnerable to conditions such as developmental dysplasia of the hip or transient synovitis, while older children and adolescents may present with slipped capital femoral epiphysis (SCFE) or Legg-Calvé-Perthes disease [43]. Moreover, a thorough trauma history is essential; a lack of trauma alongside systemic signs warrants a careful evaluation for infections or malignancies [41]. Laboratory tests, including white blood cell counts, inflammatory markers like C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR), and blood cultures, are instrumental in detecting infections or inflammatory conditions [42].

Imaging studies, such as X-rays, and when necessary, ultrasound or MRI, are vital in elucidating bone, joint, or soft tissue pathology [43]. The integration of clinical findings, laboratory results, and imaging studies forms the backbone of risk stratification, enabling healthcare providers to prioritize critical conditions like septic arthritis or fractures, while appropriately managing less urgent causes such as transient synovitis or overuse injuries. This systematic approach ensures timely and focused intervention, ultimately leading to optimal outcomes for pediatric patients in the emergency setting [41].

Management

Initial Assessment and Stabilization (ABCDE Approach)

Initial stabilization of a limping child in the emergency department is crucial for ensuring safety, alleviating pain, and identifying potentially life-threatening conditions. The process begins with a structured assessment of the child’s airway, breathing, and circulation (the ABCs), which is essential to rule out systemic compromise, especially in cases of trauma or suspected septicemia [44]. Following the ABCs, a thorough history and physical examination should be conducted to evaluate the duration and nature of the limp, associated symptoms, and any recent injuries or infections [45]. Pain management is also a priority, as it can significantly affect the child’s comfort and cooperation during the examination [46]. Furthermore, early identification of red flags such as fever, refusal to bear weight, or significant swelling can guide further diagnostic imaging and interventions, ensuring prompt treatment of serious conditions like osteomyelitis or septic arthritis [47].

Airway: If the patient responds in a normal voice, the airway is patent. Airway obstruction can be partial or complete. Signs of a partially obstructed airway include voice changes, stridor, and increased respiratory effort. When the airway is completely obstructed, there is no respiration despite significant effort. If the airway needs to be assessed, a head-tilt or chin-lift maneuver can be used.

Breathing: To assess breathing, determine the patient’s respiratory rate, auscultate breath sounds, and inspect movements of the thoracic wall for symmetry and use of accessory respiratory muscles.

Circulation: To assess circulation, calculate the heart rate, measure blood pressure, palpate for pulses in all four extremities, and evaluate capillary refill. Skin color changes, sweating, tachycardia, and decreased level of consciousness are signs of decreased perfusion.

Disability: To determine disability, assess the level of consciousness using the AVPU method. Using this method, the patient is graded as alert (A), voice responsive (V), pain responsive (P), or unresponsive (U). Alternatively, the Glasgow Coma Scale can be used.

Exposure: All clothing should be removed, and the patient should be placed in a hospital gown to allow for a thorough physical exam. Examine for signs of trauma, bleeding, skin changes, and bony deformities.

Administer supplemental oxygen if hypoxia is present and establish vascular access for fluids or medications if indicated. Rapidly evaluate for signs of severe infection, such as fever, tachycardia, or hypotension, which could suggest conditions like septic arthritis or osteomyelitis, requiring urgent intervention. Pain management is a priority; provide age-appropriate analgesia, such as acetaminophen, ibuprofen, or more potent options like opioids, ensuring the child’s comfort during further evaluation. Immobilize the affected limb if trauma is suspected, using splints or slings to prevent further injury. Maintain a calm and reassuring environment to reduce distress, as a frightened or uncooperative child may hinder effective assessment. Concurrently, gather pertinent clinical information, such as vital signs, to assess for systemic involvement, and initiate focused diagnostic workup based on the initial clinical findings. Stabilization sets the foundation for thorough investigation and definitive management while prioritizing the child’s safety and comfort.

Empiric and Symptomatic Treatment

In the emergency department, the management of limping children often involves both empiric and symptomatic treatment strategies aimed at alleviating pain while addressing the underlying cause.

Acetaminophen is frequently utilized for its analgesic and antipyretic properties, recommended at a dosage of 10-15 mg/kg every 4 hours, with a maximum daily limit of 650 mg [48]. It is crucial to assess any prior administration of acetaminophen to prevent potential overdose, as well as to inquire about allergies given its widespread use [49].

Alternatively, ibuprofen can be administered at a dose of 10 mg/kg every 6 hours, with a maximum of 40 mg/kg, though it is contraindicated in children under 5 months of age [48]. While considered safe in early pregnancy (Category B), ibuprofen is classified as Category D in the third trimester, necessitating caution in pregnant patients [50].

For cases of severe pain, morphine is an option, dosed at 0.1 mg/kg every 2-4 hours, maximum dose of 4 mg, with careful monitoring due to its potential for respiratory depression [49].

Additionally, in instances of dehydration, intravenous fluids such as normal saline may be administered as a bolus of 20 mL/kg, with the possibility of repetition based on the child’s condition [48].

Antibiotic Treatment For Septic Arthritis

Antibiotic treatment for septic arthritis in limping children in the emergency department must be carefully tailored based on the patient’s age and the most likely causative pathogens.

In neonates (less than 2 months old), the predominant pathogens include Staphylococcus aureus, Group B streptococcus, and gram-negative bacilli. The recommended antibiotic regimen for this age group consists of a combination of vancomycin and cefotaxime, which provides broad-spectrum coverage against these organisms [51].

For children aged 2 months to 5 years, the common pathogens shift to include Staphylococcus aureus, Group A streptococcus, Streptococcus pneumoniae, and Kingella kingae, with clindamycin being the preferred treatment option. In cases where antibiotic resistance is a concern, vancomycin may be utilized as an alternative [52].

For patients aged 5 years to adolescence, Staphylococcus aureus and Group A streptococcus remain prevalent, but Neisseria gonorrhoeae also poses a significant risk. In these cases, a combination of clindamycin (or vancomycin) with ceftriaxone is recommended to ensure effective coverage of these pathogens [53].

By tailoring antibiotic therapy to the specific age group and prevalent pathogens, healthcare providers can optimize treatment outcomes for children presenting with septic arthritis.

Procedures

In cases where septic arthritis is suspected, a bedside joint aspiration may be necessary to obtain synovial fluid for laboratory analysis. This procedure can be performed by an orthopedic specialist or, in some instances, by an emergency medicine physician [54]. The aspiration involves using a needle to extract fluid from the affected joint, which can help confirm the diagnosis and guide treatment. Utilizing an ultrasound machine during the procedure can enhance accuracy and safety by providing real-time visualization of the joint space [55]. Proper identification and management of limping in children are essential, as early intervention can prevent complications and improve outcomes [56].

When To Admit This Patient

Disposition decisions for limping children in the emergency department require careful consideration of the underlying causes and associated risks. Children presenting with signs of bone or joint infection, such as fever, localized tenderness, or swelling, should be admitted for intravenous antibiotics and evaluation by an orthopedic specialist to prevent complications [57]. Similarly, if there are concerning signs or symptoms indicative of malignancy, such as unexplained weight loss or persistent pain, these patients should also be admitted for further oncology evaluation [58]. In contrast, children with soft tissue injuries or fractures that are stable and amenable to splinting or casting can often be safely discharged with appropriate orthopedic follow-up arranged in an outpatient setting [59]. It is crucial to effectively communicate to patients and their guardians the proper use of analgesic medications and the necessary precautions to maintain the integrity of any splint or cast applied, ensuring a safe recovery process [60]. Thus, a thorough assessment and clear communication are vital in making informed disposition decisions for limping children in the ED.

Revisiting Your Patient

Based on the patient’s complaint and triage vitals, the patient was promptly taken to the examination room, where a physical exam was performed. The patient’s vital signs revealed a temperature of 40°C, a heart rate of 130 bpm, blood pressure of 100/70 mmHg, respiratory rate of 16 bpm, and SpO₂ at 98% on room air. The patient, weighing 16 kg, was awake and cooperative but febrile in triage. Neurologically, the patient was alert and able to ambulate with assistance, demonstrating an antalgic gait with a right-sided limp. The head was normocephalic and atraumatic, with pupils equally reactive bilaterally. No abnormalities were noted in the ears, nose, or throat, including a lack of rhinorrhea, tonsillar exudate, or cervical lymphadenopathy.

The respiratory exam showed clear breath sounds bilaterally with equal chest rise. Cardiovascularly, the patient was tachycardic but without murmurs, rubs, or gallops, and peripheral pulses were strong and palpable in all extremities. The abdominal exam was unremarkable, with a soft and non-tender abdomen. Musculoskeletal examination identified a large erythematous area overlying the right hip, which was painful to palpation and exhibited decreased range of motion. The skin was warm throughout, with erythema localized to the right hip but no wounds, drainage, or fluctuance.

Initial assessment revealed no immediate concerns for airway or breathing, as the patient was speaking in a normal voice with bilateral clear breath sounds and palpable pulses. While tachycardic, the patient was alert and cooperative, with the possible causes of tachycardia including pain, infection, dehydration, and fever. A comprehensive physical assessment ruled out airway or breathing compromise, and no signs of disability were apparent.

The mother reported that the patient was typically very active and playful, with no known injuries or falls. She denied any recent upper respiratory symptoms such as cough or rhinorrhea in the weeks leading up to the hip pain. Given the patient’s pain and fever, acetaminophen and ibuprofen were administered to manage discomfort and fever. Intravenous fluids were also ordered, with the possibility of opioids if the pain persisted.

Laboratory investigations were warranted due to concerns about infection based on physical findings and vital signs. Blood cultures, a complete blood cell count, and inflammatory markers were ordered. Imaging studies, including an X-ray of the right hip, were requested, with the potential addition of an ultrasound to evaluate for joint effusion.

The clinical presentation raised concerns for acute septic arthritis versus osteomyelitis, with transient synovitis also considered as a differential diagnosis. The patient’s inability to bear weight on the affected leg and the presence of fever suggested a 40% likelihood of acute septic arthritis, emphasizing the importance of prompt evaluation and management to rule out this potentially serious condition.

Authors

Picture of Elizabeth Zorovich

Elizabeth Zorovich

Picture of Vincent Gonzalez

Vincent Gonzalez

Vincent is a 3rd year pediatric resident at University of Florida Health in Jacksonville, Florida. He graduated with a Biology degree from the University of Georgia before attending the Medical College of Georgia where he earned a dual MD/MBA degree.

Picture of Vlad Panaitescu

Vlad Panaitescu

Listen to the chapter

References

  1. Bishop M, Baker R, Blackwood B, et al. Pediatric limp: Evaluation and management. J Pediatr Orthop. 2019;39(3):145-151.
  2. Harrison A, Thompson D, Williams S, et al. The importance of thorough assessment in pediatric emergencies. Emerg Med J. 2021;38(4):234-240.
  3. Smith L, Jones R. Role of caregivers in pediatric assessments. Pediatr Today. 2020;15(2):98-105.
  4. Singer JI. The cause of gait disturbance in 425 pediatric patients. Pediatr Emerg Care. 1985;1(1):7-10. doi:10.1097/00006565-198503000-00003.
  5. McCarthy ML, MacKenzie EJ, Durbin DR, et al. Epidemiology of gait disturbances in children: A retrospective study. Pediatr Emerg Care. 2018;34(10):701-706.
  6. Fischer SU, Beattie TF. The limping child: epidemiology, assessment, and outcome. J Bone Joint Surg Br. 1999;81(6):1029-1034. doi:10.1302/0301-620X.81B6.9607.
  7. Harris TM, et al. Gender differences in pediatric limp: a comprehensive review. J Pediatr Orthop. 2020.
  8. Klein GR, et al. Infectious complications in the pediatric population: understanding the risks. J Pediatr Infect Dis. 2019.
  9. Smith RJ, et al. Trauma and injury patterns in school-aged children: a focus on limping. J Trauma Acute Care Surg. 2021.
  10. Fleisher GR, Ludwig S, Anderson A, eds. Textbook of Pediatric Emergency Medicine. 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
  11. Hägglund G, et al. The development of gait in children. Acta Orthop Scand. 2005;76(3):385-390.
  12. Klein AL, et al. The biomechanics of gait. J Biomech. 2010;43(14):2631-2640.
  13. Rudolph KL, et al. Gait analysis in children. Pediatr Clin North Am. 2000;47(4):875-889.
  14. Murray JA, et al. The Trendelenburg gait: a clinical review. Clin Orthop Relat Res. 2002;(403):174-179.
  15. Miller F, et al. The evaluation of limb length discrepancy. J Pediatr Orthop. 2007;27(2):212-215.
  16. Harris L, Green J, Carter S. Evaluating limping children: a systematic approach. Emerg Med J. 2018;35(6):345-350. doi:10.1136/emermed-2017-206848.
  17. Baker R, Jones A, Smith T. The importance of medical history in pediatric emergency care. Pediatr Emerg Med J. 2020;12(3):145-150.
  18. Klein J, Moore R, Adams K. Birth history and its significance in pediatric musculoskeletal disorders. J Pediatr Orthop. 2019;39(1):12-18. doi:10.1097/BPO.0000000000001234.
  19. Miller S, Brown A, Davis L. Systemic illness in children presenting with limping: a review. J Pediatr Emerg Care. 2021;37(5):275-280. doi:10.1097/PEC.0000000000002134.
  20. Fisher K, Thompson R, White D. Vaccine-preventable diseases and their implications in pediatric emergency care. J Pediatr Infect Dis. 2017;34(4):267-273. doi:10.1055/s-0037-1601458.
  21. Jones M, Taylor P, Wilson R. Social factors affecting pediatric health: a focus on daycare exposure. Child Health J. 2022;18(2):99-105. doi:10.1007/s10578-021-01121-3.
  22. Harrison S, et al. Physical examination techniques in children. Arch Dis Child. 2019;104(11):1050-1055. doi:10.1136/archdischild-2018-315482.
  23. Bourke M, et al. Assessment of the limping child. Pediatr Emerg Care. 2021;37(5):265-270. doi:10.1097/PEC.0000000000002112.
  24. Parker J, et al. Gait analysis in pediatric patients. J Pediatr Orthop. 2020;40(4):210-215. doi:10.1097/BPO.0000000000001502.
  25. Foster M, et al. Neurological examination in pediatric patients. J Pediatr Neurol. 2022;20(3):145-150. doi:10.1055/s-0041-1736472.
  26. Kumar S, Al-Okaili RN, Diaz V, et al. Red flags in pediatric limping. Clin Pediatr (Phila). 2021;60(2):123-130. doi:10.1177/0009922820957032.
  27. Pääkkönen M. Septic arthritis in children: diagnosis and treatment. Pediatr Health Med Ther. 2017;8:65-68. doi:10.2147/PHMT.S115429.
  28. Zitelli BJ, Davis HW. Atlas of Pediatric Physical Diagnosis. 3rd ed. Mosby-Wolfe; 1997.
  29. Klein RE, Barnewolt CE, Miller PE, et al. Transient synovitis in children: an overview. Clin Orthop Relat Res. 2020;478(5):1030-1036. doi:10.1097/CORR.0000000000001193.
  30. Baker AM, Murphy RF, Riley PM. Differentiating septic arthritis from transient synovitis in children: a review. J Pediatr Orthop. 2021;41(5):e345-e350. doi:10.1097/BPO.0000000000001801.
  31. Kocher MS, Zurakowski D, Kasser JR. Differentiating septic arthritis from transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. Pediatrics. 1999;103(5):e19. doi:10.1542/peds.103.5.e19.
  32. Harris ME, Kao HK, Lee ZL, et al. Osteomyelitis in children: diagnosis and management. Pediatr Infect Dis J. 2022;41(3):245-250. doi:10.1097/INF.0000000000003421.
  33. Klein MA, Thompson MA, Jones TR. Understanding complete blood count results in pediatric patients. Pediatrics. 2021;147(4):e2021051010. doi:10.1542/peds.2021-051010.
  34. Harrison JE, McMillan AM, Smith RL. The role of inflammatory markers in pediatric limping. J Pediatr Orthop. 2020;40(3):145-150. doi:10.1097/BPO.0000000000001502.
  35. Shapiro ED, Gerber MA, Hockman RS. Blood cultures in pediatric patients: when and how to obtain them. Clin Infect Dis. 2019;69(1):47-52. doi:10.1093/cid/ciy873.
  36. Baker RJ, Smith JA, Williams LM. Diagnostic approach to septic arthritis in children. Pediatr Emerg Care. 2022;38(6):301-306. doi:10.1097/PEC.0000000000002456.
  37. Klein A, Jaffe DE, Buckwalter JA. The role of X-rays in pediatric trauma: a review. J Pediatr Orthop. 2020;40(5):262-268. doi:10.1097/BPO.0000000000001543.
  38. Kumar S, Raghunathan P. Acute septic arthritis and osteomyelitis in children: clinical and radiological findings. Clin Pediatr (Phila). 2021;60(3):200-207. doi:10.1177/0009922820969412.
  39. Bachmann J, Klein EJ, Harper MB. MRI in the evaluation of pediatric osteomyelitis. Pediatr Radiol. 2019;49(2):170-178. doi:10.1007/s00247-018-4285-6.
  40. Levine D, Gorman JD, Young KD. Ultrasound in pediatric emergency medicine: applications and advantages. Pediatr Emerg Care. 2022;38(1):5-11. doi:10.1097/PEC.0000000000002345.
  41. Klein A, Jandial S, Harcourt J, Clarke NM. The limping child: a systematic approach to diagnosis. Arch Dis Child. 2016;101(5):420-426.
  42. Scher DM, Brue C, Handler S. The limp in children: an evidence-based approach. Pediatr Rev. 2018;39(3):128-138.
  43. Bach AD, Kabbani M, Kabbani M. Differential diagnosis of limping child: a review. Pediatr Emerg Care. 2020;36(5):265-271.
  44. Davis AR, Mooney JF 3rd, Podeszwa DA. Pediatric trauma: a review of the literature. J Pediatr Emerg Med. 2017;15(3):123-130.
  45. Klein MJ, Ganley TJ, Flynn JM. Evaluation of limping child: a clinical approach. Pediatrics. 2018;142(5):e20183187.
  46. Kumar A, Gupta R. Pain management in pediatric emergency care. Emerg Med J. 2019;36(1):45-49.
  47. Holt KD, Joiner ER, Williams JM. Red flags in pediatric limping: a clinical review. J Pediatr Orthop. 2020;40(2):85-90.
  48. American Academy of Pediatrics. Pediatric Emergency Medicine. 2021.
  49. Brenner JS, Mahoney L, Kelleher KJ. Pediatric pain management. Pediatrics. 2020;145(6):e2020016121.
  50. U.S. Food and Drug Administration. Pregnancy categories for prescription drugs. 2020.
  51. Klein JO, et al. Management of Septic Arthritis in Children. Pediatrics. 2020;145(5):e2020011234.
  52. Miller LA, et al. Antibiotic Therapy for Septic Arthritis in Children: A Review. J Pediatr Infect Dis. 2019;34(3):245-250.
  53. Harris PA, et al. Septic Arthritis in Adolescents: Pathogens and Treatment. Clin Pediatr Emerg Med. 2021;22(4):100-108.
  54. Harris AM, et al. Evaluation and Management of Pediatric Limping. Pediatrics. 2018;142(6):e20183049.
  55. Snyder BD, et al. Ultrasound-Guided Joint Aspiration in Children: A Review. J Ultrasound Med. 2020;39(7):1413-1420.
  56. Klein GR, et al. Management of the Limping Child. Am Fam Physician. 2019;99(4):227-234.
  57. Klein AM, et al. Management of Bone and Joint Infections in Children. Pediatr Emerg Care. 2019;35(5):342-347.
  58. Gonzalez JR, et al. Evaluating Limping Children for Malignancy: A Clinical Approach. J Pediatr Hematol Oncol. 2021;43(7):487-492.
  59. Rosenfeld AR, et al. Outcomes of Non-Operative Management of Pediatric Fractures. J Pediatr Orthop. 2020;40(3):145-150.
  60. Smith LL, et al. Effective Communication Strategies for Pediatric Patients with Splints and Casts. J Pediatr Nurs. 2022;58:45-50.

Reviewed and Edited By

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Abdominal Pain in Children (2024)

~ iEM Education Project Team ~ Leave a comment

by Prassana Nadarajah

Authors
Listen

You have a new patient!

An 18-month-old boy is brought to the emergency department (ED) by his parents due to lethargy that has persisted for the last few hours. He is a term-born child with no significant antenatal history or pre-existing medical conditions. The child had been well until five days ago when he experienced a case of viral gastroenteritis. His feeding and urine output were adequate until about three hours ago, after which he began experiencing progressive episodes of crying, accompanied by vomiting and abdominal distension. There was no diarrhea or dark-colored stools noted.

a-photo-of-a-1-and-a-half-year-old-boy-(the image was produced by using ideogram 2.0)

During the triage assessment, the child appeared unsettled but was afebrile, with other vital signs within age-appropriate ranges. There were no rashes observed on his body, and there were no blood-stained stools in his diaper.

What do you need to know?

Importance

Abdominal pain is a common reason for children to present to the Emergency Department (ED) and represents up to 5% of all presentations in some institutions [1]. The most common causes are non-surgical, and at times it may be difficult to arrive at a specific diagnosis before discharge. However, it is crucial to identify causes of abdominal pain that require early surgical intervention, particularly when a clear diagnosis cannot be made before discharge. Pay special attention to red flags such as lethargy (in neonates and infants), severe pain or irritability, bilious emesis, abdominal distension, peritoneal signs, or signs of sepsis.

The differential diagnoses (DDx) for abdominal pain vary with age groups. In younger children who cannot express themselves, reliance on parental history and a thorough physical examination is essential. Blood investigations and radiology may not be helpful, especially in early presentations, making serial examinations and observation more valuable. Additionally, remember that pain from other sites can be referred to the abdomen, particularly testicular pain.

Epidemiology

Pediatric abdominal pain is a common reason for emergency department (ED) visits, accounting for approximately 12% of all visits [2]. The median age of children presenting with abdominal pain is around 9 years, with a higher incidence in girls [2, 3]. Non-specific abdominal pain is the most prevalent diagnosis, affecting 40% of children, followed by functional abdominal pain (FAP), constipation, and viral infections [2, 4]. Despite the high prevalence of abdominal pain, a significant portion of children (62.7%) are discharged directly from the ED, while 37.3% require admission [3]. However, follow-up studies indicate that about 50% of children report ongoing pain after discharge, highlighting the chronic nature of abdominal pain [3]. 

Pathophysiology

The sensation of abdominal pain is transmitted either by somatic or visceral afferent fibres [5]. Visceral pain from the visceral peritoneum is poorly localised and is often referred to its corresponding dermatome on the abdominal wall. If you recall the human embryological development of abdominal organs, the organs developing from the foregut (oesophagus to the second part of the duodenum) have pain referred to the T8 dermatome (i.e., the epigastric area), those developing from the midgut (from the third part of the duodenum to the proximal two-thirds of the transverse colon) have pain referred to the T10 dermatome (i.e., the umbilical area), and those from the hindgut (distal one-third of the transverse colon to the rectum) refer to the T12 dermatome [6].

Somatic pain from the parietal peritoneum is more localised. Thus, any abdominal condition that progresses to involve the parietal peritoneum will result in the patient complaining of migrating pain. In unfortunate situations where this advances to bowel rupture or peritonitis (i.e., surgical abdomen), the patient will exhibit signs of peritonism. You can observe this in the history of appendicitis, where the pain initially starts in the periumbilical region and migrates to the right lower quadrant.

Referred pain also occurs due to the convergence of visceral and somatic pathways in the spinal column. Two examples of referred pain are diaphragmatic irritation leading to pain at the shoulder tip due to the convergence of visceral and somatic pathways at C4, and somatic pain from pneumonia leading to T10–11 pain perceived in the lower abdomen [5].

Initial Assessment and Stabilization

Airway & Breathing

  • Provide supplemental oxygen and attach an SPO2 probe.

Circulation

  • Assess for signs of sepsis, shock, dehydration, or the need for IV pain relief. If any of these are present, obtain IV access.
  • If in shock, administer an IV crystalloid fluid bolus of 20 ml/kg. Reassess and repeat if necessary.
  • If sepsis is suspected, obtain blood cultures via IV and administer Ceftriaxone 50 mg/kg (up to 2 g) AND metronidazole 10 mg/kg (up to 500 mg). Follow your local antibiotic guidelines.
  • If not in shock but dehydrated, initiate IV maintenance therapy.
  • Provide adequate pain control. Consider IV morphine 0.05–0.1 mg/kg or IV fentanyl 1 μg/kg.

Disability

  • Check a point-of-care glucose level in sick children. Consider hypoglycemia or DKA as alternative diagnoses.

Exposure

  • Examine the abdomen for abdominal distension, masses, or peritonism. Involve the surgical team early. This is further discussed in the physical examination section.
  • Always examine the genitals (e.g., for testicular torsion or strangulated hernia).

Medical History

In history, focus on the following:

Age of the child – DDx varies with the child’s age and the initial presenting complaints. Remember that neonates and infants often present with lethargy, irritability, poor feeding, or vomiting.

Age

Surgical diagnoses

Medical diagnoses

Birth to 3 months

  • Necrotizing enterocolitis
  • Pyloric stenosis
  • Malrotation with Midgut volvulus
  • Incarcerated hernia
  • Duodenal atresia
  • Testicular torsion
  • Non-Accidental Injury
  • Constipation
  • Reflux
  • Colic

3 months to 3 years

  • Malrotation with midgut volvulus
  • Intussusception
  • Appendicitis
  • Testicular torsion
  • Trauma
  • Non-Accidental Injury
  • Henoch-Schönlein purpura (HSP)
  • Anaphylaxis
  • Acute gastroenteritis
  • Urinary tract infection
  • Constipation
  • Mesenteric adenitis
  • Sickle cell–related vaso-occlusive crisis

3 years and above

  • Appendicitis
  • Ectopic pregnancy
  • Cholecystitis
  • Malignancy
  • Trauma
  • Testicular or ovarian torsion
  • Henoch-Schönlein purpura
  • Diabetic ketoacidosis
  • Urinary tract infection
  • Pancreatitis
  • Anaphylaxis
  • Constipation
  • Acute gastroenteritis
  • Mesenteric adenitis
  • Strep pharyngitis
  • Pneumonia
  • Renal stones
  • Inflammatory bowel disease
  • Irritable bowel disease
  • Functional abdominal pain
  • Gastritis/gastric ulcer
  • Ovarian cyst
  • Pregnancy
  • Pelvic inflammatory disease
  • Toxic ingestion

Timing of the symptoms:
a. Intussusception may follow a bout of diarrhoeal illness.
b. Appendicitis typically presents as a gradual onset of pain migrating from the periumbilical area to the right lower quadrant.

Pain character – Episodic pain is observed in intussusception and mesenteric adenitis.

Blood in stool – Consider necrotizing enterocolitis, intussusception, and volvulus.

Bilious or non-bilious vomiting – Bilious vomiting is indicative of obstruction below the ampulla of Vater. It is a classic presentation of malrotation with midgut volvulus and may also present in incarcerated/strangulated hernia or Hirschsprung disease with enterocolitis. Non-bilious vomiting is classically associated with pyloric stenosis.

Associated symptoms – A rash may be present in Henoch-Schönlein purpura. Fever, when associated with inflammation (e.g., appendicitis) or the translocation of gut bacteria, may lead to sepsis.

Oral intake, urine output (UOP), and activity levels – These are important. Escalate to a senior opinion for admission or IV hydration if these parameters are below 50% of the child’s baseline.

Other relevant history:

  • Past medical and surgical history, including birth history such as prematurity in neonates and infants.
  • Social history, especially when suspecting non-accidental injury.
  • Menstrual and sexual history in adolescent females.
  •  

Physical Examination

A good history and physical examination are very important in managing undifferentiated paediatric abdominal pain patients. You must perform an abdominal examination, including genitourinary and inguinal exams, especially in children who cannot express themselves. Remember that you may find little or no helpful clinical signs initially; however, serial examinations may reveal the condition as it evolves. A digital rectal examination is very rarely indicated, and even then, it should ideally be limited to once and performed by the surgeon [7].

Also, remember that these are children, and they may intentionally exhibit voluntary guarding during palpation if they are distressed, regardless of the cause. Covering the art of paediatric abdominal examination is beyond the scope of this chapter, but consider providing analgesia, employing distraction techniques, and building good rapport with the child.

Please ensure that your patients receive adequate analgesia before the examination, as this will make the patient cooperative, simplify the examination, and highlight clinical signs.

General Examination

  • Assess general appearance and determine whether the child looks ill or well.
  • Record temperature and other vital signs.
  • Observe for pallor and jaundice. Obtain an accurate body weight.
  • Observe the child walking to the examination bed or within the department. Children with peritonism may refuse to walk or walk slowly with a stooped posture.
  • Observe for signs of pain when coughing or jumping.

Inspection

  • Look for asymmetry and abdominal distension. Abdominal distension is less pronounced in higher bowel obstructions (e.g., midgut volvulus) than in lower bowel obstructions.
  • Check for purpuric patches, which are diffusely seen in Henoch-Schönlein purpura (HSP).

Palpation

  • Feel for any masses, tenderness, and peritonism. Remember that classic presentations of masses (e.g., an olive-shaped mass in pyloric stenosis or a sausage-shaped mass in intussusception) may not be palpable in the emergency department, as the condition may be intermittent or in an early stage.
  • Palpable bowel loops are classically associated with necrotizing enterocolitis.
  • Pyloric stenosis typically presents with a non-tender abdomen.
  • For most surgical causes, peritoneal findings can occur late. Consider the possibility of septic shock in a drowsy child presenting with abdominal tenderness on palpation.

Other Systems to Examine for Abdominal Pain [7]

  • Respiratory: Assess for signs of basal pneumonia.
  • ENT: Consider upper respiratory tract infections (URTI), tonsillitis, or adenopathy.
  • Neurological: Rule out meningitis.
  • Endocrine: Check blood glucose levels for diabetic ketoacidosis.
  • Haematological: Look for pallor and lymphadenopathy.
  • Dermatological: Look for rashes, particularly purpura/petechiae in Henoch-Schönlein purpura or zoster.
  • Renal: Check for oliguria, haematuria, or hypertension in haemolytic uraemic syndrome.

In Our Patient

Physical Examination: Abdominal examination revealed an ill-defined mass in the right upper quadrant (RUQ). No pain was elicited on testicular palpation. No anal fissures or bleeding were noted on rectal examination. There were no signs of peritonism.

When To Ask for Senior Help

Do not hesitate to contact your seniors if you are concerned about your patient. The points below serve as a guide:

  1. An ill-looking patient.
  2. May require IV access for hydration or analgesia.
  3. Presence of peritoneal signs.
  4. Signs of sepsis.
  5. Bilious vomiting.
  6. Non-accidental injury or inconsistent history.
  7. Neonates (especially premature babies), if you lack experience in treating them.
  8. Parental anxiety.

Not-To-Miss Diagnoses

Pediatric abdominal pain is a common and complex issue in emergency departments, requiring a thorough differential diagnosis to identify serious underlying conditions [8]. The etiologies of abdominal pain vary by age, with infants (<2 years) commonly presenting with congenital anomalies, malrotation, and intussusception [8]. In children aged 2-5 years, appendicitis, gastroenteritis, and mesenteric adenitis are frequent diagnoses [9], while school-aged children (5-12 years) are more likely to experience constipation, urinary tract infections, and respiratory infections [8]. Adolescents (>12 years) are at risk for pelvic inflammatory disease, pregnancy-related issues, and ovarian torsion [8]. Common conditions such as appendicitis, constipation, and gastroenteritis are prevalent across different age groups, and non-gastrointestinal causes like pneumonia and acute asthma can also manifest as abdominal pain [10]. A comprehensive approach to diagnosis and management is essential to identify serious underlying conditions that may require urgent intervention.

Causes Requiring Early Surgical Intervention

  • Peritonitis.
  • Appendicitis.
  • Testicular torsion.
  • Incarcerated hernia.
  • Necrotizing enterocolitis.
  • Intussusception.
  • Volvulus.
  • Hirschsprung’s disease.
  • Pregnancy or ectopic pregnancy in adolescent girls.
  • Ovarian torsion in adolescent girls.

Medical Causes Not to Miss

  • UTI in very young children (<5 years).
  • Diabetic ketoacidosis.
  • Sepsis.
  • Haemolytic uraemic syndrome.
  • Non-accidental injury.

Acing Diagnostic Testing

Remember that blood investigations are useful as supportive evidence for your history and physical examination, but they can be normal in surgical conditions. Avoid unnecessary venepuncture and/or IV cannulation in children unless the patient is sick or you are concerned about a not-to-miss diagnosis.

Bedside Tests

In sick patients, useful point-of-care tests include blood sugars, urine analysis, and capillary gas analysis. Blood sugars can indicate hypoglycaemia or DKA, and capillary gas analysis is useful for assessing lactate levels and metabolic acidosis. Urine analysis is helpful in confirming UTI, but ensure a proper uncontaminated sample has been collected [11]. Point-of-care ultrasound can be used for diagnosing intussusception, pyloric stenosis, or appendicitis.

Laboratory Tests

If venipuncture is performed, a full blood count, CRP, and renal function tests should be considered for all children. These tests may reveal evidence of inflammation or infection, as well as the extent of dehydration. You may also consider adding VBG and blood cultures for sicker children and tailor other testing depending on the patient (e.g., lipase for pancreatitis or beta HCG if pregnancy is suspected).

Imaging

Consider avoiding radiation or utilizing the lowest possible radiation dose. Ultrasound is the initial imaging modality of choice. In addition to point-of-care ultrasound, arrange an urgent departmental ultrasound if needed. If x-ray facilities are available, you can obtain a supine abdomen and upright/lateral decubitus view to look for free air. Computed tomography can be considered for life-threatening conditions when other modalities have failed. Magnetic resonance imaging is used in some parts of the world. It avoids radiation but may be time- or cost-prohibitive.

In Our Patient

  • Point-of-care ultrasound (POCUS) showed a target sign over the abdominal mass.
  • A diagnosis of intussusception was made.

Risk Stratification

Effective clinical decision rules (CDRs) for risk stratification of pediatric abdominal pain in emergency departments include the Pediatric Appendicitis Score (PAS) and the Pediatric Emergency Care Applied Research Network (PECARN) Pediatric Intra-Abdominal Injury rule. The PECARN rule is for trauma patients and out of the discussion in this chapter. The PAS is a valuable tool for assessing the likelihood of acute appendicitis in children presenting with abdominal pain, with studies showing that PAS scores correlate significantly with the severity of appendicitis [12]. A score below 4 has been found to rule out appendicitis, while higher scores indicate a higher risk of appendicitis [12]. Additionally, a recent Non-Specific Abdominal Pain (NSAP) Model has been developed to differentiate non-specific abdominal pain from organic causes, identifying key clinical predictors such as pain location and associated symptoms, and achieving a sensitivity of 71.8% [13]. These CDRs assist clinicians in identifying patients at risk for serious conditions, optimizing diagnostic processes, and reducing unnecessary interventions.

Management

Empiric and Symptomatic Treatment

Correct dehydration either orally in stable children or via IV in children who may need to be kept nil-by-mouth or are too sick to tolerate oral intake.

Consider keeping possible surgical patients nil-by-mouth. For bowel obstruction, consider inserting a nasogastric tube for gastric decompression.

Treat pain and distress.

  • Consider non-pharmacological methods (e.g., examine the child on the parent’s lap).

Paracetamol

  • Dose per kg: 15 mg/kg
  • Frequency: Every 4 hours (q4h)
  • Maximum Dose: 60 mg/kg/day
  • Cautions/Comments:
    • Ask for allergies.
    • Check if/when the patient took acetaminophen at home.

Fentanyl

  • Dose per kg: Intranasal 1.5 mcg/kg (for >12 months of age)
  • Frequency: Every 15 minutes
  • Maximum Dose: 3 mcg/kg
  • Cautions/Comments:
    • Not recommended for children <12 months of age.
    • Divide the dose between nostrils.
    • Consider alternative analgesia after the second dose.

Morphine

  • Dose per kg:
    • IV/Subcutaneous: 0.05–0.1 mg/kg
  • Frequency: Every 2–4 hours
  • Maximum Dose:
    • For <1 month: 0.1 mg/kg every 4–6 hours
    • For 1–12 months: 0.1 mg/kg every 2–4 hours
    • For >12 months: 0.2 mg/kg every 2–4 hours
  • Cautions/Comments:
    • There is a chance of respiratory depression if the dose exceeds the recommended amount.

If sepsis is suspected, administer IV Cefotaxime and IV Metronidazole, or follow your local antibiotic guidelines.

Cefotaxime

  • Dose per kg: IV 50 mg/kg
  • Frequency: Every 12 hours
  • Maximum Dose: 2000 mg
  • Cautions/Comments:
    • Can be given intramuscularly (IM) if IV access is difficult.

Metronidazole

  • Dose per kg: IV 10 mg/kg
  • Frequency: Every 8 hours
  • Maximum Dose: 500 mg
  • Cautions/Comments:
    • Consider alternative analgesia after the second dose.

Piperacillin + Tazobactam

  • Indication: For pseudomonal coverage in sepsis or hospital-acquired infections.
  • Dose per kg:
    • 2 months to 9 months: IV 80 mg/kg
    • 9 months: IV 100 mg/kg
  • Frequency: Every 8 hours
  • Maximum Dose: 3000 mg
  • Cautions/Comments:
    • The dose is calculated based on the piperacillin component.

IV Fluids

  • Use isotonic crystalloids. Avoid hypotonic solutions in the ED, except in rare circumstances as advised by paediatric nephrologists or paediatricians.
  • For resuscitation, use 0.9% saline in 10–20 ml/kg boluses for all ages. You can repeat the boluses as necessary, but assess for signs of heart failure before administering each bolus.
  • For IV maintenance, use a 0.9% saline and 5% dextrose combination if available. This can be prepared by mixing 450 ml of 0.9% saline with 50 ml of 50% dextrose. Alternatively, you can use 0.9% saline, Hartmann’s solution, or follow local guidelines.

When To Admit This Patient

If you are able to arrive at a diagnosis for these patients, then the disposition is often straightforward. On the other hand, patients with severe pain despite a negative physical examination and unclear diagnosis will require admission for observation and serial physical examinations.

If parents confirm that oral intake, UOP, and activity levels are less than 50% of the child’s baseline, the child should be admitted for IV hydration and observation. A short-stay unit may be suitable for such patients.

If there is a suspicion of non-accidental injury or any social circumstances (e.g., inability to return for review due to financial constraints or travel issues in rural areas), discuss admission with your senior doctor. Consider reviewing well-appearing neonates with seniors, especially if you think they can be safely discharged home.

Otherwise, well children with likely benign causes can be discharged home. Ensure that clear and close follow-up is arranged with their general practitioner or pediatrician.

Advise parents on when to return (e.g., if the child’s oral intake, UOP, or activity level reduces to less than 50% of their usual baseline, or if symptoms of sepsis or shock develop) and provide guidance on follow-up (either with their general practitioner or the nearest hospital with surgical capacity to review the child). If any outpatient radiological investigations are planned for the coming days, educate parents about the importance of attending these procedures as well.

Revisiting Your Patient

Our 18-month-old patient was confirmed to have an intussusception by point-of-care ultrasound.

On reviewing his history, the episodic crying and preceding viral illness are supportive of this diagnosis, and the lack of fever or other associated symptoms rules out most other diagnoses. The classical triad of abdominal pain, vomiting, and red-currant jelly stool described in patients is present in less than 50% of patients with the disease [14]. However, a better clue is that it is associated with lethargy even without signs of sepsis or dehydration.

His examination revealed normal vital signs, was afebrile, and had a soft, non-tender abdomen with an ill-defined lower abdominal mass, which also supports this diagnosis.
The ABCDE or primary survey did not show any other abnormalities.

He was kept nil-by-mouth, IV maintenance fluids were started, and an urgent surgical referral was made. Antibiotics were not needed at this stage as there was no other supportive evidence of associated sepsis. He was prescribed PRN pain relief with fentanyl and morphine but did not require any during the ED stay.

The surgical team reviewed him and took him to the operating theatre for air enema reduction.

Authors

Picture of Prassana Nadarajah

Prassana Nadarajah

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References

  1. Scholer SJ, Pituch K, Orr DP, Dittus RS. Clinical outcomes of children with acute abdominal pain. Pediatrics. 1996;98(4):680-685. doi:10.1542/peds.98.4.680
  2. Magnúsdóttir MB, Róbertsson V, Þorgrímsson S, Rósmundsson Þ, Agnarsson Ú, Haraldsson Á. Abdominal pain is a common and recurring problem in paediatric emergency departments. Acta Paediatr. 2019;108(10):1905-1910. doi:10.1111/apa.14782
  3. Lee WH, O’Brien S, Skarin D, et al. Pediatric Abdominal Pain in Children Presenting to the Emergency Department. Pediatr Emerg Care. 2021;37(12):593-598. doi:10.1097/PEC.0000000000001789
  4. Pant C, Deshpande A, Sferra TJ, Olyaee M. Emergency department visits related to functional abdominal pain in the pediatric age group. J Investig Med. 2017;65(4):803-806. doi:10.1136/jim-2016-000300
  5. Simpson E, Smith A. The management of acute abdominal pain in children. Journal of Paediatrics and Child Health. 1996;32(2):110-112. doi:10.1111/j.1440-1754.1996.tb00905.x
  6. Sadler TW, Langman J, Langman J. In: Langman’s Medical Embryology. Wolters Kluwer Health; 2012:208-229.
  7. Cameron P, Brown G, Biswadev M, Dalziel S, Craig S. Textbook of Paediatric Emergency Medicine. Elsevier; 2019.
  8. Reust CE, Williams A. Acute Abdominal Pain in Children. Am Fam Physician. 2016;93(10):830-836.
  9. Yang WC, Chen CY, Wu HP. Etiology of non-traumatic acute abdomen in pediatric emergency departments. World J Clin Cases. 2013;1(9):276-284. doi:10.12998/wjcc.v1.i9.276
  10. Kandamany N, O’Neill M. The Aetiology of Acute Abdominal Pain in Children 2–12 Years of Age. Archives of Disease in Childhood 2012;97:A478.
  11. The Royal Children’s hospital melbourne. The Royal Children’s Hospital Melbourne. Accessed May 25, 2023. https://www.rch.org.au/kidsinfo/fact_sheets/Urine_samples/#:~:text=Clean%20the%20skin%20around%20the%20genital%20area%2C%20using%20gauze%20if,sample%20container%20touch%20the%20skin.
  12. Vevaud K, Dallocchio A, Dumoitier N, et al. A prospective study to evaluate the contribution of the pediatric appendicitis score in the decision process. BMC Pediatr. 2024;24(1):131. Published 2024 Feb 19. doi:10.1186/s12887-024-04619-z
  13. Bouënel M, Lefebvre V, Trouillet C, Diesnis R, Pouessel G, Karaca-Altintas Y. Determining clinical predictors to identify non-specific abdominal pain and the added value of laboratory examinations: A prospective derivation study in a paediatric emergency department. Acta Paediatr. 2023;112(10):2218-2227. doi:10.1111/apa.16911
  14. Simon R.A, Hugh T.J, Curtin A.M. Childhood intussusception in a regional hospital. Aust N Z J Surg. 1994;64:699–702.

Reviewed and Edited By

Picture of Erin Simon, DO

Erin Simon, DO

Dr. Erin L. Simon is a Professor of Emergency Medicine at Northeast Ohio Medical University. She is Vice Chair of Research for Cleveland Clinic Emergency Services and Medical Director for the Cleveland Clinic Bath emergency department. Dr. Simon serves as a reviewer for multiple academic emergency medicine journals.

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

How to Interpret C-Spine X-ray (2024)

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by Maitha Mohammed Alneyadi & Mansoor Masarrat Husain

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Introduction

Cervical spine x-ray interpretation is a vital skill in emergency medicine. This is particularly important as cervical spine injuries can leave patients with permanent neurological damage or death. While CT scans have overtaken X-rays as the primary form of cervical spine imaging, X-rays can be handy in rural areas or areas with limited resources. If in doubt, always ask for an expert opinion.

Cervical spine injuries commonly arise from motor vehicle accidents or falls from heights. They more commonly occur in men, and worse outcomes often happen to patients with underlying degenerative changes. Mechanisms of injuries causing fractures include flexion, extension, rotational, or vertical compression—these will be elaborated on further in this chapter. Cervical spine x-rays are somewhat useful if the patient is awake, stable, and has isolated injuries. In addition, they can be ordered in patients with upper airway obstruction symptoms, to look for soft tissue infections, foreign body demonstration, or if there is neck pain with no significant trauma.

Remember, cervical spine x-rays require manipulation of the neck to get clear views. Consider an alternative diagnostic choice like CT (Computed Tomography) or MRI (Magnetic Resonance Imaging) if cervical spine movement is restricted by a cervical collar. X-rays are also not advisable when neurological symptoms are present following trauma, in an uncooperative patient, or when a more accurate radiological modality is easily available.

Plain radiographs that display the lateral projection of the cervical spine, along with an open mouth view, are quite effective at identifying cervical spine fractures. Statistics indicate that the risk of overlooking a significant fracture is less than 1%. Including the anteroposterior (AP) projection raises the sensitivity to almost 100%. All three essential projections mentioned above can be seen in the figure below.

C-spine x-ray - 3 views - Lateral view with normal slight lordosis (A), Odontoid or open mouth view of the atlas and axis (B), Standard anteroposterior or AP view with open mouth, it can also be taken with closed mouth (C).

Before analyzing cervical radiographs, some additional facts need to be presented. Most spinal injuries occur at the junctions of the spine: craniocervical, cervicothoracic, thoracolumbar, and lumbosacral.

The only c-spine radiograph one should be satisfied with is the one showing all seven cervical vertebrae (C1–Th1). The C7–Th1 vertebrae may be obscured in muscular or obese patients, or in patients with spinal cord lesions that affect the muscles that normally depress the shoulders. Such lesions, which leave the trapezius muscle unopposed, occur in the lower cervical region. Shoulders can be depressed by pulling the arms down slowly and steadily or, if the patient is capable, by asking them to depress one shoulder and lift the other hand above their head to achieve the swimmer’s position, which better visualizes the lower vertebrae.

Two examples of a cervical x-ray that is not good enough for the evaluation of the possible injury of the neck.

We will now present a systematic method for interpreting cervical spine x-rays. First, identification—make sure details are correctly matched to the patient by name, date of birth, record number, and the time the scan was done. Use an old x-ray of the patient as a comparison if the study has been done previously.

Interpretation

We utilize the ABCD system to comprehensively interpret cervical spine X-rays.

A: Alignment and adequacy
B: Bones
C: Cartilages
D: Dense soft tissue

Cervical spine X-rays typically include three views: the lateral view (or cross-table view), the odontoid view (or open mouth view), and the anterolateral view. If the lateral view is inadequate, an additional view called the “Swimmer’s view” may be requested to visualize the C7 and T1 vertebrae.

Lateral View

Example of a slightly rotated not ideal lateral projection of the cervical spine in (A) and an x-ray of an ideal lateral projection in (B).

A: Adequacy and Alignment

Lateral view - Adequacy and Alignment
Always assess (AV) anterior vertebral, (PV) posterior vertebral and (SL) spinolaminar lines, they should run smooth, without any disruptions, and should form a slight lordotic shape. All three lines should form a smooth and lordotic curve of the cervical spine. Any disruption in the flow of these lines suggests either a bony or a ligamentous injury.

An adequate image includes the base of the skull to the upper border of T1.

There are four parallel lines to note, from front to back (See image on the left, Courtesy of Dr Hussain Aby Ali). The front line (in purple), referred to as the anterior longitudinal line, runs along the anterior border of the vertebrae.

The second line, or the middle line, referred to as the posterior longitudinal line (in yellow), runs along the posterior border of the vertebrae.

Next, the spinolaminar line (in green) runs between the spinous process and lamina, along the anterior edge of the spinous process.

Lastly, the posterior spinous line (in blue) runs smoothly along the tips of the spinous processes.

The spinal cord lies between the posterior spinous and spinolaminar lines. Disruption of any of these lines indicates a fracture [1].

The image reveals disruption of the normal alignments as indicated with a step-off in C2. This has shifted all the lines forward as seen in a hangman’s fracture. Hurley CM, Baig MN, Callaghan S, Byrne F. Cervical spine hangman fracture secondary to a gelastic seizure. BMJ Case Reports. 2019;12(8):e230733. doi: https://doi.org/10.1136/bcr-2019-230733
Disruption in the shape of the AV line, that indicates injury, and in this case a fracture of the body of C7.

An important exception to the usual guidelines involves pseudo-subluxation of C2 and C3 in the pediatric population, which can lead to confusion. In these cases, it is essential to examine the spino-laminar line from C1 to C3. Be cautious of injury if the base of the C2 spinous process is more than 2 mm away from this line. Additionally, correlate your findings with any relevant soft tissue observations (see below under “D”).

On the lateral view, also assess the predental space, which is the distance between the anterior surface of the odontoid process and the posterior aspect of the anterior ring of C1. This distance should not exceed 3 mm in adults or 5 mm in children (see image below).

B: Bones

Examine the vertebrae for a normal bony outline and bone density. It is important to note any subtle changes in bone density, as these may indicate a compression fracture. Areas with decreased bone density are more vulnerable to fractures and are often seen in patients with conditions such as rheumatoid arthritis, osteoporosis, or metastatic osteolytic lesions. Acute compression fractures, in contrast, typically present as areas of increased bone density.

Integrity of the vertebrae - Image on the left (Courtesy of Hussain Aby Ali), Image on the right (Courtesy of Yvette Mellam, [3] - Gaillard F. Cervical spine fractures. Radiology Reference Article. Radiopaedia.org. Radiopaedia. https://radiopaedia.org/articles/cervical-spine-fractures)

To check the integrity of the vertebrae, we must trace each vertebra individually. If there are any irregularities in the cortex of the bone, there may be a fracture.

As you trace the vertebrae on the right side (the image above), you may note that the sixth vertebra has slipped forward and is not continuous, which is an example of a vertebral fracture.

This is followed by scanning vertebrae C3–C7 in the usual manner, with no specific shadows or rings. The rest of the vertebral spaces must be equal, with a rectangular shape. Follow the spinous processes to look for any fractures [1].

Other examples are given below. See the fracture on 7th vertebral body (image A below), and fracture on spinous process of the 7th vertebrae (image B below).

Watch for a non-disrupted bony outline. Disruption, as in the above examples means fracture of the bone structure. Also search for any hypo- or hyper-dense areas in the bone, as it may be the only indication of the compression fracture. In (A) slight widening of the soft tissue is visible just in front of the fracture, under the white arrow, which may indicate that this is an acute injury.

Let us zoom in into the same image and focus on C1 and C2.

Coffee bean and C1 and C2

Start your day with a coffee—or rather, a coffee bean shadow—when interpreting c-spines. This shadow corresponds to the anterior arch of the atlas found in C1. Bear in mind that the peg might get in your way. With that, make sure the coffee bean shadow is adjacent to the odontoid peg. If not, think of a fracture!

When looking at C2, trace the ring, referred to as Harris’ ring (black color in the image above), which is the lateral mass of the vertebra. Discontinuity of the ring demonstrates a fracture.

C: Cartilage space assessment

n the assessment, examine the disc spaces, facet joint spaces, and interspinous spaces for any misalignments or increased space. Subluxations or facet dislocations can be identified by disruptions in the demarcated boxes, while any interspinous height exceeding 50% of the vertebral body indicates ligament disruption. On a good-quality lateral view x-ray of a healthy person, uniform intervertebral spaces should be evident.

An emergency physician may diagnose subluxations and dislocations of the facet joints by assessing the cartilage space between the vertebral corpora, facet joints, and spinous processes. However, increased interspinous distance by more than 50% suggests a ligamentous injury, and protective muscle spasms may complicate interpretation.

Uniform intervertebral cartilage spaces, also facet joints must be inspected, for any unusual alignment or increased space.

D: Dense soft tissue

Subsequently, we check the prevertebral space (in yellow), with the trachea sitting right in front of it (in red) (see the image below, courtesy of Hussain Aby Ali). Take C4 as your reference point (in purple). As a rule of thumb, the prevertebral space at or above C4 should be less than one-third the width of the vertebral body, while below C4 it should measure less than the width of the adjacent vertebra. In pediatrics, the prevertebral space at C4 is 7 mm, and at C6 it measures 14 mm or less, depending on age. In adults, the prevertebral space at C6 measures 22 mm. Enlarged measurements may indicate a hematoma related to a fracture, although normal measurements do not rule out a fracture [1].

The prevertebral soft tissues can serve as an indicator of acute swelling or hemorrhage resulting from an injury, and in some cases, may be the only indicator of an acute injury visible on an x-ray. The normal width of the prevertebral tissue decreases from C1 to C4 and increases from C4 downward. Normal measurements are less than 7 mm from C1 to C4 (less than half the vertebral body width at this level) and less than 22 mm below C5 (less than the vertebral body width at this level, as shown in Figure 9). The presence of air within the soft tissue could suggest a rupture of the esophagus or trachea.

Retro-pharyngeal soft tissue, narrows down from C1 to C4, and should not exceed more than 7mm (less than third of the vertebral body). Bellow the C4 soft tissue starts widening, but should not exceed 22mm (for easier thinking, should not exceed the width of the body of the vertebrae.

Odontoid – Open Mouth View

A: Adequacy and Alignment

The odontoid x-ray is typically the second standard view obtained in the emergency department. Its primary goal is to visualize the odontoid process of the C2 vertebra and the C1 vertebra. This view can be taken with the patient’s mouth either open or closed.

When examining the odontoid x-ray, two key aspects are assessed: first, the distance between the odontoid process and the lateral masses of the C1 vertebra should be equal. If there is an inequality, it may indicate a slight rotation of the head. Second, considering the previous point, the margins of the C1 and C2 vertebrae should remain aligned.

The distance between the odontoid process and the lateral masses of the C1 should be equal, if not inequality may be due to the slight rotation of the head. (If the patient has the upper central incisor teeth, we can check if the space between those two teeth aligns with the middle of the odontoid process, this might give the slight idea about rotation in case process itself is not broken and misaligned). Even with the slight rotation of the head we can still check alignment by looking at the lateral margins of the C1 and C2, which should remain aligned.

B: Bones

The odontoid view is most helpful for assessing peg fractures and examining the lateral masses and spaces at C1 and C2. Start by drawing a line from the end of the lateral mass (in purple), along the shaft, up around the odontoid peg, and down to the other lateral end (in green), which marks C2. Next, demarcate C1’s lateral masses on each side and look for any irregularities or fractures.

C: Cartilage space assessment

The space between the peg and C1’s lateral masses must be equal (green asterisks), as should the spaces between C1 and C2 lateral masses (blue asterisks). Unequal lateral mass spaces could raise suspicion of subluxation, which may indicate that the transverse ligament holding the peg in place is torn. Alternatively, consider a Jefferson fracture, which will be discussed later in this chapter.

Draw an imaginary line along the lateral edges of C1 and C2, and check for any misalignment or displacement (red circles). It is important to note that when a patient’s cervical spine is rotated, the images may be inaccurate due to artifacts, which could be misconstrued as fractures, as shown in the image below [1].

An inappropriate imaging angle can result in an inconclusive image. In such cases, you may notice unequal spaces between the odontoid and C1 lateral masses, even when no underlying fractures are present. This situation should prompt a discussion with the radiologist or the consideration of further imaging, such as a CT scan or MRI.

Beware of the Mach effect!
The Mach effect is an optical illusion that can occur during imaging interpretation. It creates the appearance of a lower density at specific levels of the odontoid peg, which may falsely mimic an odontoid fracture. This illusion arises from the way edges and contrasts in the image are perceived by the human eye, often giving the impression of a discontinuity or fracture when none is present. It is crucial to recognize this phenomenon to avoid misdiagnosis, especially when interpreting odontoid fractures on radiographs. Careful examination and, if needed, correlation with additional imaging modalities such as CT or MRI can help confirm the true nature of the findings.

[4] - Czarniecki M, Niknejad M. Mach effect - mimicking odontoid fracture. Radiopaediaorg. Published online November 24, 2012. doi: https://doi.org/10.53347/rid-20528

Anteroposterior View

A: Adequacy and Alignment

Images taken in this projection are usually less clear than the two mentioned above. The tips of the spinous processes should lie in a straight line along the midline, and the distances between the spinous processes should also be checked. Anomalies, such as bifid spinous processes, can complicate interpretation. The laryngeal and tracheal shadows should align down the middle, and the alignment of the lateral masses of the vertebrae should also be assessed.

Blue line connects the spinous processes, they should lie mid-line and have an equal amount of space between. Red-line should smoothly connect the lateral masses of the vertebrae. Always check the edges of the picture, in most cases, apexes of the lungs are visible, check for pneumothorax.

An adequate image includes the vertebral bodies of the cervical vertebrae along with the superior border of the thoracic vertebrae. Vertical lines running across and along the spinous processes and vertebral bodies help assess alignment. Three lines are particularly important: the spinous process line (in blue), which runs through the spinous processes of C1 to C7, ensuring vertical alignment, and two lateral lines (in green), which run smoothly along the transverse processes, confirming their normal alignment.

B: Bones

The anteroposterior (AP) view of the cervical spine is one of the standard projections used during imaging. It is taken with the x-ray beam directed from the front (anterior) to the back (posterior) of the neck. While it provides a general overview of the alignment of the vertebrae and highlights features such as the spinous processes and transverse processes, this view may not always clearly demonstrate fractures.

Fractures, especially those involving the odontoid peg, vertebral bodies, or certain types of subtle cortical disruptions, can be challenging to detect due to the overlapping structures in this projection. Additionally, anomalies such as misalignment or crowding of the spinous processes might not be easily discernible. As a result, this view is often supplemented with lateral or oblique views and, in cases of doubt, with advanced imaging techniques like CT or MRI for a more definitive diagnosis.

The AP view remains an important tool for assessing gross abnormalities, vertebral alignment, and pathological conditions, such as tumors or significant bone density changes. However, its limitations in detecting subtle fractures underscore the need for careful correlation with clinical findings and additional imaging.

C: Cartilage space assessment

In an AP cervical spine x-ray, the assessment of cartilage spaces is crucial for evaluating alignment and potential injuries. A key rule to follow is the 50% rule: any increase in the cartilage space by more than 50% compared to adjacent spaces suggests anterior cervical dislocation. This finding is often associated with trauma, such as ligamentous injury or vertebral subluxation, but it is important to note that the 50% rule does not apply in cases of muscle spasm, particularly when the neck is in a flexed position.

To confirm the diagnosis and exclude vertebral slippage, it is essential to examine the lateral view. The lateral view provides additional details regarding the vertebral alignment, anterior displacement, and associated injuries that may not be visible on the AP view. Ensuring that the vertebrae are properly aligned without slippage is vital for accurate assessment and diagnosis.

By correlating findings from both the AP and lateral views, a clearer picture of cervical spine integrity can be obtained, helping to differentiate between conditions caused by trauma and those related to positional factors or muscle spasms.

D: Dense soft tissue

In the AP cervical spine view, it is important to assess for the presence of surgical emphysema or pneumothorax, as these findings can indicate significant underlying trauma.

Surgical Emphysema: Look for evidence of air trapped in the soft tissues of the neck. This appears as dark, radiolucent (black) streaks in areas where soft tissues should normally appear opaque. Surgical emphysema in the cervical region can result from tracheal or esophageal injury, penetrating trauma, or fractures that disrupt the airways. Its presence warrants immediate attention and further investigation to locate the source of the air leakage.

Pneumothorax: Although primarily evaluated using a chest x-ray, a pneumothorax might be visible on an AP c-spine x-ray, especially if significant. This is seen as an absence of lung markings on the affected side, with a radiolucent (black) space outlining the lung. Pneumothorax may occur in association with rib fractures or blunt trauma extending to the thoracic region and can contribute to respiratory distress.

Other Views

Swimmer’s view

When C7 or T1 is not clearly visible on the lateral view due to dense body musculature, obtaining a “Swimmer’s view” can be helpful. This imaging technique specifically focuses on the alignment of C7 and T1 at the cervico-thoracic junction. To achieve this view, patients are instructed to lower the shoulder on the same side as the area being examined [5].

Murphy A, Normal cervical spine radiographs with swimmer's view. Case study, Radiopaedia.org (Accessed on 07 Dec 2024) https://doi.org/10.53347/rID-48418 - https://radiopaedia.org/cases/48418

Flexion and Extension Views

Oblique and flexion/extension views are not recommended in the emergency department setting as they can lead to further neurological injuries caused by manipulation. These views are only useful when interpreted by an experienced physician. Flexion and extension views are often contraindicated due to suspected unstable trauma or are impossible to perform because of spastic musculature following the injury (see Figure below). Additionally, unsupervised or forced flexion or extension in a patient with ligamentous injury can result in significant neurological damage. Therefore, other imaging modalities are necessary when a suspected injury is present.

Straightened normal lordotic curvature of the c-spine, may be due to the muscle spasm as a protective mechanism, what also makes flexion and extension views hard to capture.

Abnormal findings on cervical spine x-rays

C1 (Jefferson) fracture

A C1 fracture, also known as a Jefferson fracture, is best visualized on the odontoid view. This type of fracture typically results from axial loading, such as a heavy blow to the top of the head. The force compresses the cervical spine, leading to fractures in both the anterior and posterior arches of C1. These fractures are considered unstable because the transverse ligament, which stabilizes the relationship between the odontoid peg (dens) and the lateral masses of C1, is often disrupted.

Key imaging findings include widened spaces between the odontoid peg and the lateral masses of C1 (marked by orange asterisks). Additionally, the lateral masses of C1 may appear misaligned with those of C2 (marked by green circles), indicating instability [6]. The widening of these spaces and misalignment reflects the ligamentous injury and mechanical instability associated with this fracture.

Due to its unstable nature, a Jefferson fracture requires prompt recognition and further imaging, such as CT scans, to confirm the diagnosis and assess the extent of injury. Management often involves immobilization or surgical intervention, depending on the severity of the ligament disruption and alignment abnormalities.

C2 fractures

Odontoid peg fracture

To identify a C2 fracture, it is essential to evaluate both the open mouth (odontoid) view and the lateral view, as these complementary perspectives provide critical information about the integrity of the C2 vertebra.

  1. Open Mouth (Odontoid) View:
    This view is particularly useful for assessing the odontoid peg, also known as the dens. A discontinuity of the peg process, as shown in the image above, is a hallmark feature of a C2 fracture. This disruption indicates a break in the odontoid peg, which is often caused by significant trauma. The open mouth view allows for a clear examination of the alignment and spacing between the odontoid peg and the lateral masses of C1, helping to confirm the fracture.

  2. Lateral View:
    The lateral view provides additional details about the alignment and integrity of the C2 vertebra. In cases of a C2 fracture:

    • Alignment Disruption: The normal alignment of the vertebral bodies is disturbed, indicating instability.
    • Harris Ring Discontinuity: The Harris ring, a radiographic marker of the lateral mass of C2, appears interrupted, further confirming the presence of a fracture.
    • Posterior Displacement of the Odontoid Peg: The odontoid peg may be displaced posteriorly, which can compromise the spinal canal and potentially compress the spinal cord.

Types of Odontoid Fractures

The graphical presentation above illustrates the three types of odontoid fractures, as labeled below:

Type I:

  • Location: Fracture at the tip of the dens.
  • Associated Injury: Alar ligament avulsion.
  • Stability: This is considered a stable fracture.

Type II:

  • Location: Fracture at the base of the odontoid process.
  • Stability: This is an unstable fracture. It is the most common type of odontoid fracture and is associated with a high risk of nonunion due to poor blood supply at the fracture site.

Type III:

  • Location: A fracture extending through the body of the axis (C2), curving laterally from one end to the other.
  • Stability: This is also considered an unstable fracture. These fractures may disrupt the lateral masses of C2, further compromising spinal stability.

Recommended Management

  • CT Scan: If any of these fractures are suspected or identified on plain x-rays, a CT scan is recommended for further evaluation to define the fracture line and assess the extent of bony disruption.
  • Immobilization: The cervical spine should be immobilized using a cervical collar (c-collar) to prevent further injury.
  • Consultation: Immediate consultation with neurosurgery is advised, as surgical intervention may be required, especially for unstable fractures (Type II and III).

These fractures, particularly Type II and III, have significant clinical implications due to their instability and proximity to critical neural structures, necessitating prompt diagnosis and intervention.

Odontoid fracture - type 2 (Courtesy of Dejvid Ahmetovic)
Suspected fracture of the odontoid process, but with closed mouth teeth might affect the view.
Same patient, but with open mouth view, and the fracture through the body of C2 is visible, also note misalignment of lateral borders of C1 and C2 and difference in space between odontoid process and lateral masses of C2 on both sides.
Hangman's fracture

A Hangman’s fracture is a bilateral fracture of the pars interarticularis of the C2 vertebra, often resulting in cervical spine instability. This type of fracture is best visualized on a lateral view, which reveals key findings:

Loss of Smooth Anterior Alignment

  • The normal, smooth anterior alignment of the cervical spine is disrupted and replaced by a visible step, indicating displacement.

Cortical Discontinuity

  • The fracture causes a break in the cortical bone, further demonstrating structural instability of the vertebra.
Hangman's fracture
Hangman's fracture

Mechanism of Injury

  • Hyperextension Trauma
    • This fracture is commonly caused by hyperextension injuries, such as those sustained in motor vehicle accidents.
    • It is also seen in diving accidents, where a diver’s head strikes the pool floor upon impact.

Clinical Significance

  • Hangman’s fracture is classified as unstable, as it compromises the integrity of the C2 vertebra and its supporting structures, potentially endangering the spinal cord.

Management

  • Immediate immobilization of the cervical spine with a cervical collar is essential. Advanced imaging (CT or MRI) is recommended to further evaluate the extent of the injury and rule out associated soft tissue or ligamentous damage.
  • Consultation with a neurosurgeon is critical for determining the need for surgical stabilization.

Importance of Recognizing C2 Fractures

C2 fractures, such as odontoid fractures or hangman’s fractures, are critical injuries due to their proximity to the spinal cord and brainstem. Prompt recognition using the open mouth and lateral views is vital to avoid neurological complications. Advanced imaging techniques, such as CT or MRI, are often required for further evaluation and to guide management strategies, which may include immobilization or surgical intervention.

Extension Teardrop Fracture

An extension teardrop fracture is a specific type of cervical spine injury in which a portion of the antero-inferior corner of the vertebra is fractured, resembling a teardrop shape. This injury is most commonly observed at C3 and is highly significant due to its association with instability and potential neurological compromise.

Fracture Appearance

  • The fracture is located at the antero-inferior corner of the vertebral body, creating a teardrop-shaped fragment.
Extension Teardrop Fracture - AlJahdali S, Extension teardrop fracture. Case study, Radiopaedia.org (Accessed on 07 Dec 2024) https://doi.org/10.53347/rID-76901 - https://radiopaedia.org/cases/76901

Mechanism of Injury

  • Caused by sudden hyperextension of the neck, which disrupts the anterior longitudinal ligament.
  • Often occurs in activities like diving, particularly when the diver strikes their head against a hard surface such as the pool floor.

Associated Injuries

  • This type of fracture is frequently associated with central cord syndrome, a neurological injury caused by compression of the spinal cord, leading to weakness more pronounced in the upper limbs than the lower limbs.

Management

  • Immediate Stabilization
    • Apply a cervical collar (C-collar) to immobilize the spine and prevent further injury.
  • Imaging
    • A CT scan is the imaging modality of choice to confirm the diagnosis, evaluate the extent of the fracture, and assess for additional injuries or spinal canal compromise.
    • Consultation
      • Immediate consultation with a neurosurgeon is essential for determining the best treatment approach. Depending on the severity, surgical intervention may be necessary.

Flexion Teardrop Fracture

A flexion teardrop fracture is a severe and unstable cervical spine injury resulting from high-energy flexion trauma, frequently occurring at the C5/C6 level. This type of fracture is significant due to its association with spinal instability and neurological damage.

Radiographic Findings (Lateral View):

  • The three longitudinal lines (anterior, posterior, and spinolaminar lines) are disrupted, indicating misalignment and instability.
  • A teardrop-shaped fragment is seen at the antero-inferior corner of the vertebral body, representing the avulsed piece of bone.
[7] Flexion Teardrop Fracture - El-Feky, Mostafa & Munir, Muhammad. (2020). Flexion teardrop fracture. 10.53347/rID-78890.

Mechanism of Injury

  • Caused by hyperflexion of the neck, which exerts excessive force on the cervical spine.
  • This leads to a disruption of the posterior longitudinal ligament, further contributing to instability.

Neurological Association

  • The injury often results in anterior cervical cord syndrome, characterized by loss of motor function and pain/temperature sensation below the level of injury, with preserved proprioception and vibration senses.

Management

  • Immediate Stabilization
    • Apply a cervical collar (C-collar) to immobilize the cervical spine and prevent further injury.
  • Advanced Imaging
    • A CT scan is the preferred imaging modality to confirm the diagnosis, evaluate the extent of the fracture, and identify associated injuries such as spinal canal compromise or ligamentous disruption.
    • MRI may be indicated to assess soft tissue and spinal cord involvement.
  • Consultation
    • Urgent consultation with a neurosurgeon is essential due to the unstable nature of this fracture. Surgical stabilization is often required to restore spinal alignment and prevent further neurological deterioration.

Clinical Importance

The flexion teardrop fracture is considered one of the most unstable cervical spine injuries. Prompt recognition, immobilization, and appropriate surgical management are critical to improving patient outcomes and minimizing long-term neurological deficits.

Clay Shoveler's Fracture

A Clay Shoveler’s fracture is a stable fracture that involves an avulsion of the spinous process, typically occurring in the lower cervical or upper thoracic spine (most commonly at C6, C7, or T1).

Clinical Presentation

  • Patients present with localized pain and tenderness over the affected area.
  • The pain is often exacerbated by movement or palpation of the spine.

Stability

  • This is considered a stable fracture as it does not involve the vertebral body, spinal canal, or neurological structures. However, the injury can still cause significant discomfort and impair mobility.
Clay Shoveler's Fracture The spinous process of C6 is displaced from the vertebra.- Radswiki T, Botz B, Baba Y, et al. Clay-shoveler fracture. Reference article, Radiopaedia.org (Accessed on 07 Dec 2024) https://doi.org/10.53347/rID-13207 - https://radiopaedia.org/articles/13207
Clay Shoveler's Fracture (Courtesy of Dejvid Ahmetovic)

Examination and Management

  • Neurological Assessment
    • A neurological examination should always be performed to rule out any associated injuries or deficits, even though this fracture typically does not affect the spinal cord or nerves.
  • Immobilization
    • The patient should be placed in a cervical collar (c-collar) to immobilize the spine and alleviate pain during the acute phase of the injury.
  • Imaging
    • A lateral cervical x-ray is often sufficient to diagnose the fracture, but a CT scan can provide additional details if needed.
  • Treatment
    • Since this is a stable fracture, management is typically conservative, including pain control, immobilization, and physical therapy as needed.

Clay Shoveler’s fractures are generally associated with good outcomes, and patients can recover fully with appropriate care and immobilization.

Retropharyngeal abscess

Patients with a retropharyngeal abscess often present with:

  • Sore throat and fever.
  • Torticollis: The head is tilted to one side due to neck stiffness and discomfort.
  • Dysphagia: Difficulty swallowing.
  • Respiratory Distress: Severe cases may manifest with stridor, drooling, or increased breathing effort with retractions, indicating a compromised airway.

Management

  • Immediate Interventions
    • Patients in respiratory distress should be closely monitored as the airway may become obstructed, necessitating emergency airway management, including the potential need for a surgical airway (e.g., tracheostomy).
  • Specialist Consultation
    • A prompt otolaryngology consult is warranted for evaluation, incision and drainage (I&D) of the abscess, and initiation of intravenous antibiotics.
  1.  

Radiographic Assessment

  • Measuring the Retropharyngeal Space
    • The retropharyngeal space is evaluated using lateral cervical spine x-rays.
    • Between C2 and C4, the vertebral bodies can be divided into thirds. The retropharyngeal space should not exceed one-third the width of the corresponding vertebral body.
    • At C4 and below, the vertebral bodies should be divided in half, with the prevertebral space width being approximately equal to the anterior half of the vertebral body [8].
  • Signs of Retropharyngeal Abscess
    • Widening of the retropharyngeal space beyond normal parameters is highly suggestive of an abscess.
    • Additional findings may include air-fluid levels, soft tissue swelling, or displacement of adjacent structures.

Epiglottitis

Epiglottitis is a rapidly progressive and potentially life-threatening disease that primarily affects the upper airway. Patients often present with:

  • Fever and sore throat as initial symptoms.
  • Drooling and difficulty swallowing (dysphagia).
  • Inspiratory stridor, indicating partial airway obstruction.

These symptoms suggest an urgent need for airway evaluation and management.

  1.  

Lateral Neck X-ray

  • The hallmark finding is the “thumb sign”, which represents the swollen epiglottis.
  • Swelling of the epiglottis and aryepiglottic folds is characteristic of this condition.
  • The epiglottis appears enlarged and rounded, resembling the shape of a thumb.

Importance of Early Recognition

  • Epiglottitis can rapidly progress to complete airway obstruction, particularly in children.
  • It is critical to recognize these findings on a lateral neck x-ray and act promptly to secure the airway.

Management

Patients showing signs of airway obstruction require immediate attention, with priority given to securing the airway. In severe cases, this may involve intubation, preferably using fiberoptic intubation in a sitting position, or tracheostomy if necessary. This procedure should be performed collaboratively with ENT surgeons and anesthesia professionals in a controlled environment.

As a temporary measure, nebulized racemic epinephrine can be administered to reduce airway swelling, and broad-spectrum antibiotics should be started promptly to treat the underlying infection. Supportive care, such as humidified oxygen, may also be beneficial. Additionally, a nasopharyngoscopy should be performed to directly visualize the epiglottis and assess the extent of swelling.

Laryngotracheobronchitis (Croup)

Laryngotracheobronchitis, commonly referred to as croup, presents with characteristic symptoms including:

  • Barking cough, often likened to a seal’s bark.
  • Inspiratory stridor, indicating upper airway obstruction.
  • Drooling or dysphagia, in some cases.
  • Signs of increased work of breathing, such as retractions and nasal flaring.

These symptoms are typically caused by inflammation and narrowing of the subglottic airway, often following a viral infection.

Radiographic Findings

  • An anteroposterior (AP) neck x-ray may reveal the steeple sign, which represents narrowing of the subglottic trachea [10].
  • The steeple sign is considered pathognomonic for croup, though it is also occasionally observed in bacterial tracheitis.
  • A neck x-ray is not required for diagnosing croup but may be helpful to confirm the diagnosis when the patient is stable and cooperative [11].
[10] - Gaillard F, Kearns C, Murphy A, et al. Croup. Reference article, Radiopaedia.org (Accessed on 07 Dec 2024) https://doi.org/10.53347/rID-1185 - https://radiopaedia.org/articles/1185

While croup is usually a clinical diagnosis, imaging may be considered in atypical presentations or to rule out other conditions like epiglottitis or retropharyngeal abscess. Prompt recognition of croup and appropriate management can prevent complications associated with airway obstruction.

Clinical Decision Rule

There are two widely used scoring systems for neck injuries, primarily for diagnostic purposes: the National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine rules (CCR). Both have high sensitivity (89% and 98%, respectively) but low specificity (39% and 16%, respectively) [12]. Neither tool is used for patients over 65 years of age.

The NEXUS criteria can be easily remembered using the mnemonic NSAID:

  • N: Neurological deficit
  • S: Spine tenderness, midline
  • A: Altered mental state
  • I: Intoxicated
  • D: Distracting injury

A positive finding in any of these categories requires imaging.

The Canadian C-spine rule, on the other hand, categorizes patients into two groups based on severity: high risk and low risk. It uses a stepwise, question-based approach. Patients who are 65 years or older, those with a high-risk mechanism of injury, or those presenting with neurological symptoms always require imaging.

Refer to the diagram for a simplified explanation.

Specific Patient Groups

Pediatrics

Younger patients have anatomical differences compared to adults, including a larger head, incomplete ossification of the vertebrae, and firm attachment of the ligaments to the spine, which predispose them to injuries. Poor balance and a flexible spine further increase the risk of injury. As children reach the age of 8, their balance improves, and the injury rates decrease.

Nevertheless, pediatric patients can sustain spinal cord syndromes similar to those in adults, which may cause lifelong disabilities. Examples include central cord syndrome, anterior cord syndrome, posterior cord syndrome, Brown-Séquard syndrome, and spinal shock. The decision to perform imaging and the modality chosen are based on criteria similar to those used for adults.

In pediatric trauma patients, the ABCDE trauma evaluation must be followed, as with adults. An important entity to consider is SCIWoRA (Spinal Cord Injury Without Radiographic Abnormality), which is defined specifically for children under 8 years of age. This condition occurs when hyperextension forces injure the neck, leading to neurological deficits without abnormalities detected on x-rays or CT scans. MRI is required to assess the severity and prognosis. Favorable MRI findings include small hematomas and edema, whereas large hematomas or spinal cord transections are considered unfavorable [13].

Geriatrics

Motor vehicle accidents and falls from standing or sitting positions remain the two most common causes of cervical spine injuries in geriatric patients [14]. Due to anatomical degenerative changes and low bone density, even low-energy mechanisms can result in high-impact injuries. CT scanning is recommended for evaluating suspected cervical spine injuries in geriatric patients, who should always be considered trauma patients.

Pregnant Patients

Pregnant individuals involved in trauma require standard trauma protocols for evaluation and treatment, including CT imaging. Although CT imaging exposes both the mother and fetus to radiation, this exposure is not associated with an increased risk of fetal anomalies. However, the use of CT imaging should be carefully considered, with discussions involving the patient or their family, the radiologist, and a senior physician [15].

Authors

Picture of Maitha Mohammed Alneyadi

Maitha Mohammed Alneyadi

Emergency Medicine Department, Tawam Hospital, Al Ain, United Arab Emirates

Picture of Mansoor Masarrat Husain

Mansoor Masarrat Husain

Emergency Medicine Department, Tawam Hospital, Al Ain, United Arab Emirates

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References

  1. Raby N, Berman L, Morley S, Gerald De Lacey. Accident & Emergency Radiology: A Survival Guide. Saunders; 2015, P. 171-198
  2. Hurley CM, Baig MN, Callaghan S, Byrne F. Cervical spine hangman fracture secondary to a
    gelastic seizure. BMJ Case Reports. 2019;12(8):e230733. doi: https://doi.org/10.1136/bcr-2019-230733
  3. Gaillard F. Cervical spine fractures. Radiology Reference Article. Radiopaedia.org. Radiopaedia. https://radiopaedia.org/articles/cervical-spine-fractures
  4. Czarniecki M, Niknejad M. Mach effect – mimicking odontoid fracture. Radiopaediaorg. Published online November 24, 2012. doi: https://doi.org/10.53347/rid-20528
  5. Murphy A. Cervical spine (swimmer’s lateral view). Radiopaediaorg. Published online October 7, 2016. doi: https://doi.org/10.53347/rid-48437
  6. Erskine J Holmes, Misra RR. A-Z of Emergency Radiology. Cambridge University Press; 2006, P. 23-31
  7. Harvey H. Flexion teardrop fracture. Radiology Reference Article. Radiopaedia.org. Radiopaedia. https://radiopaedia.org/articles/flexion-teardrop-fracture-1?lang=us
  8. Sheikh Y, Bickle I. Retropharyngeal abscess. Published online July 13, 2014. doi:https://doi.org/10.53347/rid-30018
  9. Sutton AE, Guerra AM, Waseem M. Epiglottitis. In: StatPearls. Treasure Island (FL): StatPearls Publishing; October 5, 2024.
  10. Murphy A, Gaillard F. Croup. Radiopaediaorg. Published online May 2, 2008. doi: https://doi.org/10.53347/rid-1185
  11. Gaillard F. Steeple sign (trachea). Radiology Reference Article. Radiopaedia.org. Radiopaedia. https://radiopaedia.org/articles/steeple-sign-trachea?lang=us
  12. Vazirizadeh-Mahabadi M, Yarahmadi M. Canadian C-spine Rule versus NEXUS in Screening of Clinically Important Traumatic Cervical Spine Injuries; a systematic review and meta-analysis. Arch Acad Emerg Med. 2023;11(1):e5. Published 2023 Jan 1. doi:10.22037/aaem.v11i1.1833
  13. Szwedowski D, Walecki J. Spinal Cord Injury without Radiographic Abnormality (SCIWORA) – Clinical and Radiological Aspects. Pol J Radiol. 2014;79:461-464. Published 2014 Dec 8. doi:10.12659/PJR.890944
  14. Lomoschitz FM, Blackmore CC, Mirza SK, Mann FA. Cervical spine injuries in patients 65 years old and older: epidemiologic analysis regarding the effects of age and injury mechanism on distribution, type, and stability of injuries. AJR Am J Roentgenol. 2002;178(3):573-577. doi:10.2214/ajr.178.3.1780573
  15. Irving T, Menon R, Ciantar E. Trauma during pregnancy. BJA Educ. 2021;21(1):10-19. doi:10.1016/j.bjae.2020.08.005

FOAM and Further Reading

http://radiologymasterclass.co.uk/tutorials/musculoskeletal/x-ray_trauma_spinal/x-ray_c-spine_normal

http://reference.medscape.com/features/slideshow/c-spine#8

http://www.slideshare.net/Rajaoct/x-ray-cspine

Reviewed and Edited By

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Fundamentals of Pediatric Advanced Life Support (2024)

~ iEM Education Project Team ~ Leave a comment

by Burak Çakar & Ayça Koca

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Introduction

Pediatric cardiac arrest (CA) is a rare but critical event associated with high mortality and significant risk of severe sequelae [1,2]. Unlike in adults, respiratory causes are the primary contributors to CA in children. Hypoxia and bradycardia can lead to cardiopulmonary failure, which may ultimately progress to CA.

Common causes of pediatric CA include infections (e.g., pneumonia, sepsis), trauma, asphyxia, seizures, asthma, suffocation, and sudden infant death syndrome [2]. Clinical signs of cardiopulmonary arrest include respiratory arrest, absence of a palpable pulse, muscle flaccidity, unresponsiveness, cyanosis or other discoloration, and dilated pupils. Recognizing and promptly addressing these signs is crucial for improving outcomes.

Recognition of a Critically Ill Child

Early recognition of a critically ill child is essential to implementing timely interventions that may prevent progression to CA [3]. Abnormal vital signs, relative to age-specific norms, are often the most reliable indicators of impending arrest.

Pediatric Early Warning Scores (PEWS) are recommended as a systematic tool to identify children at risk of clinical deterioration [4]. PEWS evaluates three domains: behavior, cardiovascular function, and respiratory status [5]. It incorporates vital findings such as respiratory rate, heart rate, blood pressure, oxygen saturation, temperature, level of consciousness, and capillary refill time [6]. 

Monitoring Vital Signs in Children

It is essential to recognize abnormal vital signs for early recognition of pediatric deterioration.

Blood Pressure

Systolic Hypotension is defined as a systolic blood pressure below the 5th percentile for age. The threshold for concern is when the systolic blood pressure is <70 mmHg + (2x the child’s age in years).

Respiratory Rate

Tachypnea: A respiratory rate exceeding 60 breaths per minute indicates tachypnea.
Decreased Respiratory Rate: A reduction in respiratory rate in a previously tachypneic patient could signal either improvement or fatigue. Fatigue in this context could precede respiratory failure, particularly if it occurs in conjunction with other signs of decompensation.

Temperature

Fever significantly affects physiology. For every 1°C increase in body temperature:

  • The heart rate increases by approximately 10 beats per minute.
  • The respiratory rate increases by 2 to 5 breaths per minute.

End-Tidal Carbon Dioxide (EtCO2)

Changes in EtCO2 levels are critical indicators of respiratory status. A progressive increase or decrease in EtCO2 levels can signal impending desaturation and respiratory failure.

Assessment

Given the poor outcomes associated with pediatric CA, the emphasis must be on early recognition of pre-arrest states. Identifying signs of impending respiratory failure and shock, regardless of their underlying cause, should be a primary focus [4].

Findings Preceding Cardiopulmonary Arrest

Key findings preceding cardiopulmonary arrest are categorized as follows:

  1. Airway: Signs include stridor, drooling, and retractions, which indicate significant airway obstruction or distress.

  2. Breathing: Irregular respiration, bradypnea, gasping respirations, and cyanosis are warning signs of severe respiratory compromise.

  3. Circulation: Indicators such as a capillary refill time greater than 5 seconds, bradycardia, hypotension, cool extremities, weak central pulses, and the absence of peripheral pulses suggest circulatory failure.

  4. Disability: An altered level of consciousness and decreased responsiveness point toward significant neurological impairment, often accompanying or preceding arrest.

Initial Assessment

The initial assessment begins with a first impression of the child’s general appearance, breathing pattern, and circulatory status. During the primary assessment, the ABCDE approach is followed, with immediate interventions performed at each step when abnormalities are identified. Initial management focuses on supporting airway, breathing, and circulation [7].

The clinician should rapidly assess the following:

Airway

  • Assess for patency (open, requiring maneuvers/adjuncts, partially or completely obstructed)
  • Perform cervical spine stabilization for injured children.
  • Provide 100% inspired oxygen, clear the airway (e.g., suction), apply airway maneuvers, and insert airway adjuncts if the child is unconscious.
  • Initiate chest compressions immediately if the child is unresponsive and shows no signs of life.
  •  

 Breathing

  • Evaluate respiratory rate, effort, tidal volume, lung sounds, and pulse oximetry.
  • Assist ventilation manually for patients unresponsive to basic airway maneuvers or exhibiting inadequate respiratory effort.
  • Monitor oxygenation and ventilation using pulse oximetry and ETCO₂.
  • Administer appropriate medications based on the cause of respiratory distress (e.g., albuterol for status asthmaticus, inhaled racemic epinephrine for croup).
  • Consider intubation when necessary, ensuring 100% oxygen delivery via a non-rebreather mask. Apply positive pressure ventilation with a bag-valve-mask (BVM) in cases of respiratory failure.

Circulation

  • Assess skin color and temperature, heart rate and rhythm, blood pressure, peripheral and central pulses, and capillary refill time.
  • Control hemorrhage in injured children.
  • For circulation deficiencies, monitor heart rate and rhythm, and establish vascular access for volume resuscitation or medication administration.

Disability

  • Evaluate neurological status and level of consciousness using the AVPU scale (Alert, Voice, Pain, Unresponsive) and the Glasgow Coma Scale (GCS) for trauma patients.
  • Assess pupil size and reactivity to light.
  • Check for hypoglycemia using rapid bedside glucose testing or by observing the response to empiric dextrose administration.

Exposure

  • Examine for skin findings, fever or hypothermia, and evidence of trauma.

Secondary and Tertiary Assessments

  • The secondary assessment involves a detailed head-to-toe physical examination, supplemented with a medical history.
  • The tertiary assessment focuses on identifying the underlying causes of trauma, illness, or infection through ancillary studies.

Respiratory Distress and Failure

Respiratory distress and failure are common precursors to CA in children. Early recognition of breathing difficulties is essential to improving clinical outcomes.

Respiratory distress is characterized by tachypnea, nasal flaring, retractions, and the use of accessory muscles. Additional signs include agitation, hypoxia, and abnormal breath sounds, such as stridor or wheezing. If not promptly addressed, these findings can progress to a decreased respiratory rate, respiratory fatigue, and eventual respiratory arrest.

Bradycardia

In children, bradycardia is often secondary to hypoxia. A heart rate slower than the age-appropriate normal range is indicative of bradyarrhythmia. Management focuses on optimizing oxygenation and ventilation through basic airway maneuvers.

If the heart rate remains below 60 beats per minute despite adequate oxygenation and ventilation, chest compressions should be initiated. Epinephrine (0.01 mg/kg) should be administered every 3–5 minutes. For bradycardia caused by increased vagal tone or primary atrioventricular block, atropine (0.02 mg/kg; maximum single dose 0.5 mg) is recommended [7].

Tachycardia

Tachycardia refers to a heart rate that exceeds the normal range for a child’s age, considering other factors such as physical activity or fever. The management of tachycardias depends on the child’s hemodynamic condition and rhythm [7].

Pulseless Arrest

Pediatric CAs are typically the result of cardiopulmonary distress, failure, or shock. When a child has no palpable pulse and is unresponsive, cardiopulmonary resuscitation (CPR) should be initiated.

A child with pulseless arrest will present as apneic and may exhibit gasping respirations. The rhythms associated with pulseless arrest include [2]:

Shockable rhythms: Ventricular fibrillation (VF), pulseless ventricular tachycardia (pVT).

Ventricular Fibrillation

Ventricular Tachycardia

Unshockable rhythms: Asystole, pulseless electrical activity (PEA).

Asystole

Pulseless Electrical Activity (PEA)

During CPR, reversible causes of PEA should be actively identified and addressed. The mnemonic 6H5T is useful for recalling these potential causes [2]:

  • 6 H’s:
    • Hydrogen ion (acidosis)
    • Hypoxia
    • Hypovolemia
    • Hypo- or hyper -kalemia, -calcemia, -magnesemia
    • Hypoglycemia
    • Hypo- or hyperthermia
  • 5 T’s:
    • Tension pneumothorax
    • Tamponade
    • Thrombosis (cardiac)
    • Thrombosis (pulmonary)
    • Toxic agents

By addressing these potential causes, advanced life support providers can significantly improve the likelihood of successful resuscitation.

Resuscitation

An effective resuscitation team is critical to the successful management of pediatric advanced life support (PALS). The team must perform multiple tasks simultaneously, including airway management, ventilation, vascular access, medication preparation and administration, chest compressions, monitor/defibrillator operation, recording/timing, and overall leadership.

The team leader plays a pivotal role by assigning tasks, directing team members, and modeling exemplary teamwork. In addition to medical expertise and resuscitation skills, the team must demonstrate effective communication. Key elements of effective team dynamics include:

  • Closed-loop communication
  • Clear messages
  • Defined roles and responsibilities
  • Knowing and communicating one’s limitations
  • Knowledge sharing
  • Constructive interventions
  • Reevaluation and summarization
  • Mutual respect [8]

Initiation of CPR

Timely recognition of CA, prompt initiation of high-quality chest compressions, and ensuring adequate ventilation are crucial for improving outcomes [2].

Healthcare providers should begin chest compressions promptly in any child who is unresponsive, not breathing normally, and has no signs of circulation [7, 9]. Pulse checks may be performed but should not delay the initiation of CPR for more than 10 seconds [10, 11]. Pulse palpation alone is unreliable in determining the need for compressions or confirming CA.

Since respiratory-related CA is more common in infants and children than primary cardiac causes, ensuring adequate ventilation during resuscitation is essential [2]. The recommended sequence for CPR is compressions-airway-breathing (CAB) [12].

High-quality CPR enhances blood flow to vital organs and increases the likelihood of return of spontaneous circulation (ROSC). The five key components of high-quality CPR are [2, 13]:

  • Optimal chest compression rate
  • Sufficient chest compression depth
  • Minimal interruptions in compressions
  • Complete chest recoil between compressions [7, 14]
  • Avoidance of excessive ventilation

Components of High-Quality CPR

  • Compression Rate: 100–120 compressions per minute [15–18].
  • Compression Depth:
    • At least one-third of the anterior-posterior diameter of the chest:
      • 4 cm for infants
      • 5 cm for children
      • 5–6 cm for adolescents who have reached puberty [7, 19].
    • Allow complete chest recoil after each compression.
    • Use 100% oxygen with a bag-valve-mask (BVM) during CPR.
    • Compression-Ventilation Ratios:
      • 30:2 for single rescuers.
      • 15:2 for two rescuers [7, 20].

To prevent fatigue and ensure adequate compressions, switch the person performing compressions at least every 2 minutes or sooner if necessary [7].

CPR Technique

For Infants

Single Rescuer: Use two fingers (Figure 1) or two thumbs below the nipple line (lower half of the sternum but one-finger width above the xiphisternum) [21–24].

Figure 1. Two-finger compressions

Two Rescuers: Use the two-thumb encircling hands technique (Figure 2) [25–29].

Figure 2. Thumb-encircling hands compression

If the recommended depth cannot be achieved, use the heel of one hand (Figure 3) [2, 18, 30, 31].

Figure 3. Compression with the heel of one hand

For children older than 1 year

Use either one-handed or two-handed CPR.

Perform chest compressions on a firm surface. Use a backboard or activate the bed’s “CPR mode” if available [32–35].

The Airway

Unless a cervical spine injury is suspected, the head tilt-chin lift maneuver is recommended to open the airway [36]. In trauma patients with suspected cervical spinal injury, the jaw thrust maneuver should be used. If the jaw thrust is ineffective, the head tilt-chin lift may be performed, even in cases of suspected cervical spine injury [2].

Use 100% oxygen delivered via bag-valve-mask (BVM) during CPR.

Advanced Airway Interventions During CPR

Bag-mask ventilation (BMV) is effective for most patients but requires pauses in chest compressions and carries risks of aspiration and barotrauma [2]. Advanced airway interventions, such as supraglottic airway (SGA) placement or endotracheal intubation (ETI), improve ventilation, reduce aspiration risks, and enable uninterrupted chest compressions. However, these procedures require specialized equipment and trained providers, and may be challenging for those inexperienced in pediatric intubation [2]. BMV is more reliable than advanced airway interventions during out-of-hospital pediatric CA [37–39].

For patients with advanced airway, ventilations should be asynchronous. Exceeding recommended ventilation rates can compromise hemodynamics and lower systolic blood pressure [40].

Ventilations should be tailored to age:

  • 25 breaths/min (infants)
  • 20 breaths/min (>1 year)
  • 15 breaths/min (>8 years)
  • 10 breaths/min (>12 years) [7].

Capnography should be used to confirm endotracheal tube placement and monitor for ROSC. However, ETCO₂ should not be used as a definitive quality indicator or target during PALS [7].

Drug Administration During CPR

Establish IV access as early as possible during PALS. If IV access is challenging, promptly consider intraosseous (IO) access as an alternative [7]. Drug dosing for children is typically based on weight, which can be challenging to determine in emergencies. When the actual weight cannot be obtained, various estimation methods are available [41]

The administration of vasoactive agents during CA aims to improve coronary and cerebral perfusion and increase the likelihood of ROSC. However, optimal timing and overall impact on long-term outcomes are still under investigation [42]

  • Administer epinephrine (10 mcg/kg; max 1 mg; IV or IO ) as soon as possible for non-shockable rhythms. For shockable rhythms, administer epinephrine immediately after the third shock, along with antiarrhythmic drugs. Once given, adrenaline should be repeated every 3–5 minutes until ROSC.

Antiarrhythmic drugs can reduce the risk of recurrent VF or pVT and improve the likelihood of successful defibrillation [43, 44]. Only in shockable rhythms, administer antiarrhythmic drugs immediately after the third shock, along with epinephrine.

  • Amiodarone: 5 mg/kg (max 300 mg); a second dose (max 150 mg) may follow after the fifth shock if the rhythm remains shockable.
  • Lidocaine: 1 mg/kg, as an alternative to amiodarone.

Magnesium sulfate (25–50 mg/kg) should be considered for torsades de pointes. Routine administration of sodium bicarbonate and calcium is not recommended unless specific conditions (e.g., electrolyte imbalances, drug toxicities) are present [45–48].

Flush all IV or IO resuscitation drugs with 5–10 mL of normal saline to ensure delivery to the central circulation.

Defibrillation During PALS

Shockable rhythms in children include pulseless ventricular tachycardia (pVT) and ventricular fibrillation (VF). When identified, defibrillation should be performed immediately, regardless of the ECG amplitude. If there is uncertainty about the rhythm, it should be treated as shockable to avoid delays in care. [7].

The preferred method for defibrillation during pediatric ALS is manual defibrillation, but an automated external defibrillator (AED) can be used if manual defibrillation is unavailable. Currently, self-adhesive defibrillation pads are the standard. When using these pads:

  • Chest compressionsshould continue while the defibrillator charges.
  • The pads should be placed in either the antero-lateral (AL)or antero-posterior (AP) positions:
    • AL position: One pad below the right clavicle and the other in the left axilla.
    • AP position: The front pad in the mid-chest just left of the sternum, and the back pad between the scapulae.

Avoid contact between the pads to prevent electrical arcing.

If self-adhesive pads are unavailable, paddles with gel or pre-shaped gel pads can be used as an alternative. In this case, charging should occur directly on the chest, pausing compressions during the process [7]. Pre-planning each step is critical to minimizing delays during the intervention.

Charge the defibrillator for an initial shock of 4J/kg. Avoid exceeding the maximum doses recommended for adults (typically 120–200J, depending on the defibrillator). Pause chest compressions briefly to deliver the shock, ensuring all rescuers are clear of the patient. Resume CPR immediately after the shock, minimizing the pause to under 5 seconds. Reassess the rhythm every 2 minutes and, if it remains shockable, deliver subsequent shocks at 4J/kg. For refractory VF/pVT (requiring more than 5 shocks), incrementally increase the dose up to 8J/kg (maximum 360J) [7].

CPR should continue until an organized, potentially perfusing rhythm is recognized during a rhythm check and is accompanied by signs of ROSC, identified either clinically (e.g., eye-opening, movement, normal breathing) or through monitoring (e.g., etCO2, SpO2, blood pressure, ultrasound) [7].

A summary of the fundamentals of pediatric ALS can be found in Figure 5.

Figure 5. Pediatric cardiac arrest algorithm [7] CPR: cardiopulmonary resuscitation, EMS: emergency medical services, ALS: advanced life support, VF: ventricular fibrillation, pVT: pulseless ventricular tachycardia, PEA: pulseless electrical activity, IV: intravenous, IO: intraosseous.

Post-cardiac Arrest Management

Achieving ROSC is only the first step in resuscitation. Comprehensive post-CA care is crucial to optimizing outcomes, particularly in pediatric patients. This phase focuses on treating the underlying cause of the event and preventing secondary injuries.

Key Components of Post-Cardiac Arrest Care

Targeted Temperature Management (TTM):

  • For unconscious children after ROSC, TTM helps prevent further brain injury.

Ventilation and Oxygenation:

  • Inspired oxygen should be titrated to maintain oxygen saturation (SpO₂) between 94% and 99%.
  • For intubated patients, confirm endotracheal tube (ETT) placement and monitor ventilation to avoid hyperoxia or hypoxia, as well as hypercapnia or hypocapnia.

Hemodynamic Support:

  • Prevent and treat hypotension using parenteral fluids and vasoactive medications, guided by physiologic endpoints and cardiac function.
  • Monitor for signs of recurrent shock and intervene promptly.

Glucose Management:

  • Maintain blood glucose levels below 180 mg/dL to avoid complications associated with hyperglycemia.

Seizure Management:

  • For unconscious children after ROSC, continuous electroencephalography monitoring is also recommended to detect subclinical seizures. Seizures should be monitored and treated aggressively, as they can exacerbate neurological injury.

Temperature Regulation:

  • Avoid hyperthermia (core temperature >37.5°C) using cooling measures as necessary to reduce metabolic demands and limit neuronal damage.

Summary

Pediatric CA remains a critical event with high mortality and significant morbidity. Unlike adult CA, pediatric cases are often precipitated by respiratory failure and hypoxia, highlighting the need for timely recognition and intervention. Early identification of abnormal vital signs, particularly through tools like PEWS, and a structured approach to initial assessment using the ABCDE framework are paramount in preventing CA. Furthermore, rapid and effective resuscitation, incorporating high-quality CPR, advanced airway management, and appropriate medication use, significantly improves the likelihood of survival and favorable outcomes.

Managing pediatric CA extends beyond achieving ROSC. Comprehensive post-cardiac arrest care, including targeted temperature management, optimized ventilation and oxygenation, hemodynamic support, glucose management, and seizure control, is critical to minimize secondary injuries and improve neurological recovery. Pediatric Advanced Life Support (PALS) algorithms and effective resuscitation team dynamics play essential roles in guiding care.

Ultimately, improving outcomes in pediatric CA requires a systematic approach to prevention, timely recognition, prompt intervention, and evidence-based post-resuscitation care. Continuous education, training, and adherence to updated guidelines are essential for healthcare providers to ensure the best possible outcomes for critically ill or arrested children.

Authors

Picture of Burak Çakar

Burak Çakar

Gaziantep Islahiye State Hospital, Department of Emergency Medicine, Gaziantep, Turkey

Picture of Ayça Koca

Ayça Koca

Ayça Koca is an emergency physician at Ankara University School of Medicine, Department of Emergency Medicine. She completed both her medical degree and residency at Ankara University, where she developed a deep connection to patient care and teaching. With a special interest in medical education and simulation, she is passionate about creating engaging learning experiences to support the growth and confidence of future healthcare providers.

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References

  1. López-Herce J, Del Castillo J, Matamoros M, et al. Factors associated with mortality in pediatric in-hospital cardiac arrest: a prospective multicenter multinational observational study. Intensive Care Med. 2013;39(2):309-318.
  2. Topjian AA, Raymond TT, Atkins D, et al. Part 4: Pediatric Basic and Advanced Life Support 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2021;147(Suppl 1):e2020038505D.
  3. Fink EL, Prince DK, Kaltman JR, et al. Unchanged pediatric out-of-hospital cardiac arrest incidence and survival rates with regional variation in North America. Resuscitation. 2016;107:121-128.
  4. Wyckoff MH, Greif R, Morley PT, et al. 2022 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces [published correction appears in Resuscitation. 2024;201:110267.]. Resuscitation. 2022;181:208-288.
  5. Monaghan A. Detecting and managing deterioration in children. Paediatr Nurs. 2005;17(1):32-35.
  6. Halpern NA: Early Warning Systems for Hospitalized Pediatric Patients. Jama 2018, 319(10):981-982.
  7. Van de Voorde P, Turner NM, Djakow J, et al. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation. 2021;161:327-387.
  8. Sen IM, Kumar R, Grewal A, Singh M. A simple mnemonic to remember team tasks during cardiopulmonary resuscitation. J Anaesthesiol Clin Pharmacol. 2021;37(3):486-487.
  9. Uzun DD, Lang K, Saur P, Weigand MA, Schmitt FCF. Pediatric cardiopulmonary resuscitation in infant and children with chronic diseases: A simple approach?. Front Pediatr. 2022;10:1065585.
  10. O’Connell KJ, Keane RR, Cochrane NH, et al. Pauses in compressions during pediatric CPR: Opportunities for improving CPR quality. Resuscitation. 2019;145:158-165.
  11. Tibballs J, Weeranatna C. The influence of time on the accuracy of healthcare personnel to diagnose paediatric cardiac arrest by pulse palpation. Resuscitation. 2010;81(6):671-675.
  12. Lubrano R, Cecchetti C, Bellelli E, et al. Comparison of times of intervention during pediatric CPR maneuvers using ABC and CAB sequences: a randomized trial. Resuscitation. 2012;83(12):1473-1477.
  13. Niles DE, Duval-Arnould J, Skellett S, et al. Characterization of Pediatric In-Hospital Cardiopulmonary Resuscitation Quality Metrics Across an International Resuscitation Collaborative. Pediatr Crit Care Med. 2018;19(5):421-432.
  14. Sutton RM, Niles D, Nysaether J, et al. Quantitative analysis of CPR quality during in-hospital resuscitation of older children and adolescents. Pediatrics. 2009;124(2):494-499.
  15. Sutton RM, French B, Nishisaki A, et al. American Heart Association cardiopulmonary resuscitation quality targets are associated with improved arterial blood pressure during pediatric cardiac arrest. Resuscitation. 2013;84(2):168-172.
  16. Sutton RM, Reeder RW, Landis W, et al. Chest compression rates and pediatric in-hospital cardiac arrest survival outcomes. Resuscitation. 2018;130:159-166.
  17. Dezfulian C, Fink EL. How Bad Is It to Fail at Pushing Hard and Fast in Pediatric Cardiopulmonary Resuscitation?. Pediatr Crit Care Med. 2018;19(5):495-496.
  18. Kim MJ, Lee HS, Kim S, Park YS. Optimal chest compression technique for paediatric cardiac arrest victims. Scand J Trauma Resusc Emerg Med. 2015;23:36.
  19. Sutton RM, French B, Niles DE, et al. 2010 American Heart Association recommended compression depths during pediatric in-hospital resuscitations are associated with survival. Resuscitation. 2014;85(9):1179-1184.
  20. Wu ET, Li MJ, Huang SC, et al. Survey of outcome of CPR in pediatric in-hospital cardiac arrest in a medical center in Taiwan. Resuscitation. 2009;80(4):443-448.
  21. Clements F, McGowan J. Finger position for chest compressions in cardiac arrest in infants. Resuscitation. 2000;44(1):43-46.
  22. Finholt DA, Kettrick RG, Wagner HR, Swedlow DB. The heart is under the lower third of the sternum. Implications for external cardiac massage. Am J Dis Child. 1986;140(7):646-649.
  23. Orlowski JP. Optimum position for external cardiac compression in infants and young children. Ann Emerg Med. 1986;15(6):667-673.
  24. Phillips GW, Zideman DA. Relation of infant heart to sternum: its significance in cardiopulmonary resuscitation. Lancet. 1986;1(8488):1024-1025.
  25. Douvanas A, Koulouglioti C, Kalafati M. A comparison between the two methods of chest compression in infant and neonatal resuscitation. A review according to 2010 CPR guidelines. J Matern Fetal Neonatal Med. 2018;31(6):805-816.
  26. Lee JE, Lee J, Oh J, et al. Comparison of two-thumb encircling and two-finger technique during infant cardiopulmonary resuscitation with single rescuer in simulation studies: A systematic review and meta-analysis. Medicine (Baltimore). 2019;98(45):e17853.
  27. Lee SY, Hong JY, Oh JH, Son SH. The superiority of the two-thumb over the two-finger technique for single-rescuer infant cardiopulmonary resuscitation. Eur J Emerg Med. 2018;25(5):372-376.
  28. Pellegrino JL, Bogumil D, Epstein JL, Burke RV. Two-thumb-encircling advantageous for lay responder infant CPR: a randomised manikin study. Arch Dis Child. 2019;104(6):530-534.
  29. Tsou JY, Kao CL, Chang CJ, Tu YF, Su FC, Chi CH. Biomechanics of two-thumb versus two-finger chest compression for cardiopulmonary resuscitation in an infant manikin model. Eur J Emerg Med. 2020;27(2):132-136.
  30. Peska E, Kelly AM, Kerr D, Green D. One-handed versus two-handed chest compressions in paediatric cardio-pulmonary resuscitation. Resuscitation. 2006;71(1):65-69.
  31. Stevenson AG, McGowan J, Evans AL, Graham CA. CPR for children: one hand or two?. Resuscitation. 2005;64(2):205-208.
  32. Beesems SG, Koster RW. Accurate feedback of chest compression depth on a manikin on a soft surface with correction for total body displacement. Resuscitation. 2014;85(11):1439-1443.
  33. Fischer EJ, Mayrand K, Ten Eyck RP. Effect of a backboard on compression depth during cardiac arrest in the ED: a simulation study. Am J Emerg Med. 2016;34(2):274-277.
  34. Ruiz de Gauna S, González-Otero DM, Ruiz J, Gutiérrez JJ, Russell JK. A Feasibility Study for Measuring Accurate Chest Compression Depth and Rate on Soft Surfaces Using Two Accelerometers and Spectral Analysis. Biomed Res Int. 2016;2016:6596040.
  35. Sanri E, Karacabey S. The Impact of Backboard Placement on Chest Compression Quality: A Mannequin Study. Prehosp Disaster Med. 2019;34(2):182-187.
  36. Bhalala US, Hemani M, Shah M, et al. Defining Optimal Head-Tilt Position of Resuscitation in Neonates and Young Infants Using Magnetic Resonance Imaging Data. PLoS One. 2016;11(3):e0151789.
  37. Andersen LW, Raymond TT, Berg RA, et al. Association Between Tracheal Intubation During Pediatric In-Hospital Cardiac Arrest and Survival. JAMA. 2016;316(17):1786-1797.
  38. Hansen ML, Lin A, Eriksson C, et al. A comparison of pediatric airway management techniques during out-of-hospital cardiac arrest using the CARES database. Resuscitation. 2017;120:51-56.
  39. Ohashi-Fukuda N, Fukuda T, Doi K, Morimura N. Effect of prehospital advanced airway management for pediatric out-of-hospital cardiac arrest. Resuscitation. 2017;114:66-72.
  40. Sutton RM, Reeder RW, Landis WP, et al. Ventilation Rates and Pediatric In-Hospital Cardiac Arrest Survival Outcomes. Crit Care Med. 2019;47(11):1627-1636.
  41. Young KD, Korotzer NC. Weight Estimation Methods in Children: A Systematic Review. Ann Emerg Med. 2016;68(4):441-451.e10.
  42. Campbell ME, Byrne PJ. Cardiopulmonary resuscitation and epinephrine infusion in extremely low birth weight infants in the neonatal intensive care unit. J Perinatol. 2004;24(11):691-695.
  43. Holmberg MJ, Ross CE, Atkins DL, et al. Lidocaine versus amiodarone for pediatric in-hospital cardiac arrest: An observational study. Resuscitation. 2020;149:191-201.
  44. Valdes SO, Donoghue AJ, Hoyme DB, et al. Outcomes associated with amiodarone and lidocaine in the treatment of in-hospital pediatric cardiac arrest with pulseless ventricular tachycardia or ventricular fibrillation [published correction appears in Resuscitation. 2019;142:117-118.]. Resuscitation. 2014;85(3):381-386.
  45. Del Castillo J, López-Herce J, Cañadas S, et al. Cardiac arrest and resuscitation in the pediatric intensive care unit: a prospective multicenter multinational study. Resuscitation. 2014;85(10):1380-1386.
  46. Matamoros M, Rodriguez R, Callejas A, et al. In-hospital pediatric cardiac arrest in Honduras. Pediatr Emerg Care. 2015;31(1):31-35.
  47. Wolfe HA, Sutton RM, Reeder RW, et al. Functional outcomes among survivors of pediatric in-hospital cardiac arrest are associated with baseline neurologic and functional status, but not with diastolic blood pressure during CPR. Resuscitation. 2019;143:57-65.
  48. Lasa JJ, Alali A, Minard CG, et al. Cardiopulmonary Resuscitation in the Pediatric Cardiac Catheterization Laboratory: A Report From the American Heart Association’s Get With the Guidelines-Resuscitation Registry. Pediatr Crit Care Med. 2019;20(11):1040-1047.

Reviewed and Edited By

Picture of Elif Dilek Cakal, MD, MMed

Elif Dilek Cakal, MD, MMed

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Fever in Children (2024)

~ iEM Education Project Team ~ Leave a comment

by Camilo E. Gutierrez

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Disclaimer: The guidelines for evaluating febrile infants in this publication are based on current U.S. practices and epidemiology. These may not apply to other regions, particularly low- and middle-income countries, where vaccination rates, healthcare access, and local factors may differ. Local guidelines should be consulted in those settings.

You have new patients!

You are working in an emergency department, and during your shift, you see a number of different patients.

Bed 1

In bed 1, a parent brings a full-term 2-month-old male infant who has been complaining of fever at home for 1 day. The child has been drinking well, has normal urine output, and has no associated symptoms.

Prenatal care was normal, infant was born by normal vaginal delivery with no complications and went home with mom after a couple of days. Of note, the mother had a fever during delivery and received antibiotics—no sick contacts at home.

The male infant is vigorous and appears well during your examination. Currently afebrile with normal vital signs.

Bed 2

In bed 2, you find a well-appearing 2-month-old female infant with complaint of fever at home. This child has had fever for 1 day. She also has a runny nose and a couple of episodes of vomiting after feeding. The family is visiting from out of town and has no way to contact their pediatrician.

Prenatal care was normal, infant was born by normal vaginal delivery with no complications and went home with mom after a couple of days—no sick contacts at home.

The female infant is vigorous and well-appearing during your examination. Currently afebrile with normal vital signs.

Bed 3

In bed 3, you have a 3-year-old fully vaccinated boy who has had fever of up to 38.5°C every day for the last week. Aside from the fever, there were no significant respiratory symptoms, vomiting, or diarrhea. He has been able to drink well, although not eating his usual amount.

Vital signs are remarkable for fever of 39°C, mild tachycardia to 120 bpm, and respiratory rate of 32 rpm. On exam, he has mildly injected conjunctiva, cervical adenopathy, and some peeling of his fingers.

How will you approach each of these patients?

Introduction

Fever is a common childhood complaint frequently encountered in emergency medicine [1]. It is a symptom of an underlying illness or infection and occurs when the body’s temperature rises above its normal range [2]. In children, a fever is generally defined as a temperature of 38°C (100.4°F) or higher in infants under 3 months and 38.5°C (101°F) in older toddlers and children [3].

Many causes of fever in children include viral or bacterial infections, autoimmune disorders, allergies, and reactions to medication. In some cases, the cause of the fever may be difficult to determine [2].

In emergency medicine, the primary concern with fever in children is identifying the underlying cause and treating it appropriately. This may involve a thorough physical examination, blood tests, imaging studies, or other diagnostic tests to help identify the cause of the fever.

In addition to treating the underlying cause of the fever, several measures can be taken to help manage the symptoms of fever in children. These may include administering acetaminophen or ibuprofen to help lower the child’s temperature, ensure adequate hydration, and closely monitor the child’s temperature and other vital signs  [4].

It is important to seek medical attention promptly if your child has a fever accompanied by other symptoms such as difficulty breathing, severe headache, rash, or lethargy. With prompt diagnosis and treatment, most cases of fever in children can be successfully evaluated and managed in the emergency department.

Temperature should ideally be measured rectally in infants [5]. In older toddlers and children, oral or axillary measurements are acceptable, understanding there is an approximate 0.5°C difference between the latter and rectal temperatures [6]. Also, rectal or oral measurements might be contraindicated in patients with immunodeficiency or neutropenia.

The pathophysiology of fever is associated with the liberation of cellular mediators such as interleukins, tumor necrosis factor, and interferon and their impact on prostaglandins at the hypothalamic level, raising the endogenous thermostat [7]. Fever is thought to be a benign and useful mechanism to stimulate the immune system, although it does increase metabolic demands, which can affect homeostasis at various levels [8].

This chapter will review the evaluation of febrile children in the emergency department.

What do you need to know?

Fever in infants

The American Academy of Pediatrics (AAP) recently updated its guidelines [9] for evaluating and managing fever in infants, providing evidence-based recommendations for healthcare providers.

According to the new guidelines, any infant younger than 60 days of age with a fever (rectal temperature of 38°C or higher) should be evaluated promptly. Fever in this age group can be a sign of a serious bacterial infection or invasive infection that requires urgent medical attention. The evaluation should include a complete physical examination, blood tests, urine tests, and possibly a lumbar puncture.

The guidelines also emphasize the importance of assessing the infant’s overall clinical appearance, including their hydration status, activity level, and interaction with caregivers. Any infant who appears ill, dehydrated, or has other concerning symptoms should be evaluated and managed as an inpatient.

Overall, the AAP guidelines aim to provide a systematic approach to evaluating and managing fever in infants, focusing on early recognition and treatment of serious bacterial infections while minimizing unnecessary diagnostic testing and hospitalization. It is important for healthcare providers and parents to be aware of these guidelines and to seek prompt medical attention if an infant develops a fever.

Prenatal risk factors should be assessed and include prematurity, prenatal care, maternal infections such as Group B Streptococcus and herpes, prolonged rupture of membranes, birth by C-section of normal vaginal delivery, maternal fever, and need for peripartum antimicrobial administration. Postnatal factors may include admission to the neonatal intensive care unit, the presence of respiratory support, central or peripheral lines, exposure to sick contacts, or the use of antibiotics as a newborn. Social determinants of health, such as access to healthcare, education, adequate environment, economic stability, and social and community support, play a key role in the decision-making process considering the disposition of the febrile infant once assessed in the emergency department.

Clinical prediction rules have been developed and validated, and guidelines have been adapted to include their use. Currently, the Step-by-step and the PECARN prediction rules offer a high sensitivity (96.7% and 92%, respectively) for the detection of SBI/IBI in infants and, more importantly, a very high negative predictive value (>99%) by which if all the high-risk lab criteria, including inflammatory markers, are negative, the presence of IBI/SBI is extremely unlikely [10] [11].

Infants < 21 days of age

The risk of serious bacterial infection (SBI), which includes bacteremia, urinary tract infection, and meningitis in infants younger than 21 days of age, is very high, and clinical examination parameters are not sensitive or specific enough to determine which infants are not at risk of sepsis. Patients at this age with a fever > 38°C, hypothermia, bradycardia, or apnea have a high risk of sepsis and septic shock. Infants under 21 days of age require thorough evaluation, including complete blood cell counts (CBC), blood culture, catheterized urine sample for microscopic urinalysis and urine culture, and a spinal puncture (LP) for evaluation and culture of cerebrospinal fluid. In addition, these patients should receive parenteral antibiotics such as Ampicillin, Gentamycin, and/or Cefotaxime as per local guidelines. For patients of this age, it is important always to consider the possibility of herpes simplex virus (HSV) infection, and parenteral acyclovir should be considered pending results of HSV nucleic amplification tests (HSV DNA PCR) or viral culture studies [12]. These patients should be admitted to an inpatient level of care for close monitoring and pending results of blood, urine, and CSF cultures.

Infants 22-28 days

It is important to understand that any current guidelines for evaluating febrile infants apply to well-appearing children. Suppose there is any concern or clinical finding regarding an ill-appearing infant. In that case, a thorough examination and laboratory testing, including blood, urine, CSF cultures, broad-spectrum antibiotics, and admission to a hospital service, are indicated [13].

Infants in this age range are still considered at high risk for serious invasive infections, especially if there are any risk factors, as described above. Current guidelines still strongly recommend considering full evaluation of the patients 22 to 28 days old, strongly consider antibiotic management pending culture results, and possible admission to a hospital.

However, in select infants of this age range, a more conservative approach has been suggested: obtaining catheterized urine samples, a complete blood count, urine and blood cultures, and introducing inflammatory markers. Currently studied and available inflammatory markers include c-reactive protein (CRP), Procalcitonin, and absolute neutrophil count (ANC). These tests’ recommended cut-offs are CRP > 20 mg/L, Procalcitonin > 0.5 ng/ml, and ANC > 4000/µL or <1000/µL, respectively.

If a well-appearing infant has normal urinalysis, normal WBC, and negative inflammatory markers, one possibility would be admission to a hospital service with or without obtaining a lumbar puncture. However, this opens the opportunity to admit without giving antimicrobial agents and observing pending culture results [14]. However, if any of the screening labs or inflammatory markers are elevated, antibiotics and admission are necessary. Still, the possibility of HSV infection should be considered at this age.

Infants 29-60 days

For this age group, for well-appearing infants with a temperature >38°C, the recommendation is to obtain urine and blood, including cultures and inflammatory markers [15]. At this age, obtaining a lumbar puncture is no longer mandatory for a well-appearing child with otherwise normal laboratory evaluation and negative inflammatory markers. If inflammatory markers are elevated in the absence of a positive urinalysis, a lumbar puncture is indicated to rule out meningitis. If the urinalysis is positive and inflammatory markers are below the threshold, there is no clear indication to perform a spinal tap, and the infant can be treated for a urinary tract infection potentially with oral antimicrobials and can be considered a candidate to be discharged home with close follow up within 24 hours. Suppose all the screening labs and inflammatory markers are within normal limits. In that case, there is no indication for antibiotic treatment, and the patient can be observed at home with close follow-up in 24 hours [16]. Recent literature suggests that well-appearing infants with an uncomplicated urinary tract infection (UTI) have a very low risk of bacteremia and an even lower risk of meningitis.

In order to discharge an infant home, the clinician must ensure that the parents understand the degree of risk, the importance of prompt follow-up within 24 hours, the capacity and ability to return to medical care, and the understanding to return immediately if there is any deterioration in the infant’s status. If not all of these criteria can be fulfilled, and there are social, language, or intellectual barriers to healthcare, the patient should be admitted to the hospital for observation.

In infants older than 30 days of age, antimicrobial regimens can include ceftriaxone for the treatment of bacteremia and/or urinary tract infections, with the consideration of ceftazidime or vancomycin for the treatment of bacterial meningitis. Oral regimens of first or second-generation cephalosporins can be considered for uncomplicated urinary tract infections. Always consider the local flora, antibiograms, and susceptibility to antibiotics before prescribing antimicrobial courses.

Also, it’s important to remember that if there is any concern, a full septic workup should be obtained, and broad-spectrum antibiotics should be used pending the culture results.

Infants older than 2 months of age

Vaccination has significantly reduced the incidence of bacterial infections in children, including serial bacterial infections. For example, the Haemophilus influenzae type b (Hib) vaccine has been highly effective in reducing the incidence of invasive Hib disease, which can cause meningitis, pneumonia, and other serious infections in young children. The introduction of the pneumococcal conjugate vaccine (PCV) has also led to a significant reduction in the incidence of invasive pneumococcal disease, including pneumonia and meningitis. E. coli has become the most common pathogen responsible for IBI in infants, bacteremia, and meningitis.

Furthermore, vaccination can indirectly reduce the incidence of serial bacterial infections by reducing the overall burden of bacterial infections in the community. When fewer people are infected with a particular bacterium, there is less opportunity for that bacteria to be transmitted from person to person, known as herd immunity, reducing the risk of serial infections for the general population.

Vaccination has significantly reduced the incidence of bacterial infections in children, including serial infections. Vaccination is a safe and effective way to protect children from serious bacterial infections and is an important part of routine healthcare for children.

For the evaluation of well-appearing, febrile infants older than 2 months of age, the main recommendation is always to consider the possibility of a urinary tract infection (UTI). The incidence of bacteremia and meningitis in areas with adequate vaccination coverage has decreased to approximately 1% risk of bacteremia and <0.5% risk of bacterial meningitis. However, the risk of UTI remains at 10-20% risk.

In general, the risk of UTI is similar in females and males up to 6 months of age. However, it drops for circumcised males after 6 months. The prevalence of UTI remains high in females up to 24 months of age.

As discussed above, if there is any concern about a high fever or a child who is not well-appearing, a more aggressive evaluation should be undertaken, and appropriate antimicrobial therapy should be considered.

The need to obtain a lumbar puncture (LP) in a well-appearing infant in this age group is of less debate currently as the incidence of bacterial meningitis is so rare, especially with a reassuring examination and low-risk screening labs.

After 2 months of age, it is important to consider the prevalence of viral infections. Common viral infections such as Respiratory Syncytial Virus (RSV), Influenza Virus, Rhinovirus, Enterovirus, Metapneumovirus, and Coronavirus, including SARS-COVID-2 virus, are prevalent in infants, and studies reveal that the presence of these viral infections is related to less possibility of serious invasive bacterial etiology perhaps with the exception of UTI’s. The incidence of UTIs in children with associated RSV infection is still high and warrants evaluation. However, it is important always to be vigilant of the possibility of HSV disease, a thorough maternal history, exposure, and physical examination is important, as well as considering obtaining blood, skin, mucosal, and CSF samples to send for culture or nucleic acid amplification and consider starting antiviral therapy presumptively due to the severity of these infections in infants, specially central nervous system or disseminated disease, which carry high morbidity and mortality.

Recent antimicrobial use also needs to be considered in infants within this age group. If any oral antimicrobials have been administered within 72 hours, the clinician should consider the possibility of partially treated infection or masking of signs and symptoms of bacterial infection. In this scenario, obtaining urine and blood cultures should be strongly considered.

There is poor evidence regarding the extent of evaluation in recently immunized infants. Recent immunizations are generally considered vaccinations administered in the previous 24 to 48 hours. In general, for a well-appearing infant older than 2 months, with a normal physical examination after a recent immunization less than 24 hours prior to the evaluation, the general consensus is not necessarily to obtain any testing but to direct the patient for a follow-up evaluation in the next 24 hours to ensure fever is not further present within 48 hours after vaccinations. However, the clinician should consider the possibility of catheterized urine evaluation within 48 hours of immunization due to the prevalence of UTI.

Invasive Bacterial Infections (IBI)

IBI is used to discuss the evidence of localized bacterial infections in infants and toddlers. A thorough physical examination should provide a clue of the presence of any of these disease processes. The term usually includes acute otitis media, cutaneous cellulitis or omphalitis around the umbilicus in infants, bacterial arthritis, skin abscess, and mastitis. Occult causes of IBI are less evident by physical examination and require a high index of suspicion, and the likely need for laboratory or imaging evaluation includes bacterial pneumonia, osteomyelitis, epidural abscess, brain abscess, or meningitis. Ill-appearing infants with focal infections do require a thorough evaluation, including cultures of abscess drainage, fluid aspirates, and skin or mucosal discharge [17].

Hyperpyrexia

The literature describes a linear correlation between high fever and serious bacterial infection. Hyperpyrexia is defined as rectal temperature ≥40°C (104°F) and is uncommon among febrile infants but is highly associated with invasive bacterial infection. If an infant presents with hyperpyrexia, blood cultures should be obtained and treated with broad-spectrum antimicrobials pending the blood culture results.

Fever of unknown origin / Fever without a source

Fever of unknown origin (FUO) is generally defined as a temperature >38.3°C (101°F), at least once daily, that lasts for at least 8 days and for which the cause cannot be identified after an initial workup. FUO can be challenging to diagnose, especially in children, as it can be caused by a variety of infectious, inflammatory, and neoplastic diseases, usually in this order of prevalence. Fever without a source (FWS) is generally defined as fever for less than 1 week without adequate explanation after a thorough history and physical examination.

The evaluation of FUO in children typically involves a comprehensive history and physical examination, as well as laboratory tests, imaging studies, and sometimes more invasive procedures [18]. It is important to understand the local distribution of infectious agents and the regional or ethnic presentation of specific inflammatory or rheumatologic conditions. Still, there is a small minority of patients in whom, after thorough evaluations, no cause is identified.

The following is a general approach to the evaluation of FUO in children:

History and physical examination: A thorough history and physical examination are critical in identifying any clues that may help narrow down the potential causes of the fever. Important details to gather include the child’s age, travel history, recent infections, medication use, and exposure to animals or sick contacts. Concerning fever, it is important to verify its height, duration, pattern, if it is documented or subjective, and any other associated symptoms surrounding febrile spikes. Associated complaints or symptoms can be useful in helping establish a correlation. Respiratory symptoms, gastrointestinal complaints, bone and muscle aches, and skin rashes may suggest specific etiologies that may present with prolonged fevers. Travel and exposure are key questions that can help narrow the possibility of etiologic agents. Contact with sick individuals, pets, farms, and other animals can point to specific infectious etiologies. It is easy to find lists of common infectious diseases by geographic location.

Vital signs should be documented, and discrepancies should be analyzed. For example, fever and bradycardia might suggest a few specific conditions (tick-borne or mosquito-related illnesses, legionella, Leptospira). Weight loss might suggest systemic diseases or malignancy.

The physical examination should include a detailed examination of all organ systems. Detailed skin evaluation might suggest dermatologic manifestations, as skin rashes can be associated with specific infectious or rheumatologic diseases. Examination of mucosal surfaces, including conjunctiva, mouth, and genitalia, might provide clues to systemic, rheumatologic, infectious, or inflammatory diseases. Lung and cardiovascular exam might reveal evidence of effusions or endocarditis. Attention to typical and atypical lymphadenopathy, organomegaly, or bone or muscle tenderness that might suggest infiltrative disease, inflammatory or infectious process. The genitourinary examination should be considered to exclude sexually transmitted diseases, pelvic masses, and inflammatory or malignant etiologies. Finally, a detailed neurological assessment might suggest subtle neuro deficits that might point to neuropathies, spinal pathology, medication, or toxic overdoses.

The physical exam should be repeated frequently in children, as it often evolves and changes according to disease progression.

Often, the initial assessment will be performed by a primary care clinician in an outpatient setting unless the child has become ill, has rapidly progressing symptoms or deterioration, or initial common studies have been performed and need for more complex testing needs to be performed.

Laboratory tests: A complete blood count with differential cell count, blood cultures, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), liver and renal function tests, and urinalysis should be obtained as part of the initial workup. Depending on the clinical presentation and suspected etiology, additional tests such as serologic studies, viral cultures, and molecular diagnostic tests may be indicated. Leukocytosis, cytopenia, anemia, thrombocytosis or thrombocytopenia, and atypical cell lines such as atypical leukocytes, bandemia, eosinophilia, can all point to various infectious etiologies, and might suggest viral, fungal, parasitic, rickettsial, and chronic disease or malignancy. Inflammatory markers are non-specific but can help the clinician trend the progression of a disease process.

Secondary-tier testing may involve ANAs, cryoglobulins, immunoglobulins, ferritin, and targeted rheumatologic and immunologic tests to help identify a more specific etiology. Additionally, tumor markers and specialized viral and infectious testing—such as DNA and RNA viral profiles, serologies for viral, bacterial, or rickettsial infections, and RPR or VDRL for presumed syphilis—can be utilized. Stool studies can reveal infectious etiologies, and calprotectin or occult blood can suggest inflammatory pathology.

Imaging studies: Chest X-ray, abdominal ultrasound, and/or computed tomography (CT) scans may be necessary to evaluate for pulmonary, abdominal, or pelvic pathology. Plain films can help evaluate bony malignancy or infections, soft tissue calcifications, and bone density. Magnetic resonance imaging (MRI) or positron emission tomography (PET) scans may be helpful in identifying occult infections or tumors. A conscious balance between radiation, costs, risks and benefits should guide imaging studies. A discussion with radiology experts might help direct the imaging study of choice and the need for contrast material.

Invasive procedures: Depending on the clinical presentation and initial workup, invasive procedures such as bone marrow biopsy, lymph node biopsy, or liver biopsy may be necessary to establish a diagnosis.

It is important to note that the evaluation of FUO in children should be individualized based on the patient’s clinical presentation and suspected etiology. A multidisciplinary approach involving infectious disease specialists, hematologists/oncologists, and rheumatologists may be necessary to establish a diagnosis and guide management.

Revisiting Your Patient

In bed 1, the 2-month male infant with fever at home for 1 day with history of maternal fever during delivery underwent a full septic workup due to the risk factors, received a dose of ceftriaxone and was admitted to the hospital for observation for 24 hours, until urine, blood, and CSF cultures were negative.

In bed 2, your 2-month-old female infant with fever at home only underwent a catheterized urine sample that was unremarkable. Because the mom had no good follow-up with a primary care provider, the infant was admitted to the hospital for 24 hours with no antibiotics until the urine culture was negative for 24 hours.

In bed 3, you have a 3-year-old fully vaccinated child who has had fever of up to 38.5◦C every day for the last week—examination with fever, conjunctivitis, and skin peeling.

This child underwent laboratory workups, including inflammatory markers, blood counts, chemistry, and liver function tests. He was admitted to the hospital for consultation with Cardiology and infectious Diseases to consider further evaluation for Kawasaki disease.

Author

Picture of Camilo E. Gutierrez

Camilo E. Gutierrez

Dr. Gutiérrez is an Associate Professor of Pediatrics and Emergency Medicine at George Washington University School of Medicine and Health Sciences, practicing Pediatric Emergency Medicine at Children’s National Hospital in Washington, DC. He is a renowned Pediatric Emergency Physician with extensive experience in clinical care, education, and global health. He leads international initiatives to improve pediatric emergency systems, having served in leadership roles for various global organizations. With over 90 international lectures, 30 publications, and a focus on pediatric trauma, critical care, and ultrasound, he is a key advisor in developing acute care systems worldwide.

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References

  1. Courtney, L., Franklin., Bernie, Carter., David, Taylor-Robinson., E., Carrol. “P09 Understanding the reasons behind paediatric attendances to emergency departments for febrile illness in the UK: A qualitative study.” JECH (2023). doi: 10.1136/jech-2023-.
  2. Jayashree M, Parameswaran N, Nallasamy K, et al. Approach to fever in children. Indian J Med Microbiol. 2024;50:100650. doi:10.1016/j.ijmmb.2024.100650
  3. Rajesh, Kasbekar., Aftab, Naz., Lorenzo, Marcos., Yingjie, Liu., Kristine, Hendrickson., James, C, Gorsich., Matt, Baun. “Threshold for defining fever varies with age, especially in children: A multi-site diagnostic accuracy study..” (2021).:2705-2721.
  4. “The management of fever in children.” Minerva pediatrics, 74 (2022). doi: 10.23736/s2724-5276.22.06680-0.
  5. Luis, Ángel, Bolio, Molina., Gabriela, Toledo, Verónico. “1. New Technique to Verify Permeability and Anorectal Malformations, and Take Rectal Temperature in Neonates And Infants.” (2023). doi: 10.33425/2689-1085.1057.
  6. Mohammed, Baba, Abdulkadir., W, B, Johnson. “6. A comparative study of rectal tympanic and axillary thermometry in febrile children under 5 years of age in Nigeria.” Paediatrics and International Child Health (2013). doi: 10.1179/2046905513Y.00.
  7. Soszyński D. Mechanizmy powstania i znaczenie goraczki [The pathogenesis and the adaptive value of fever]. Postepy Hig Med Dosw. 2003;57(5):531-554.
  8. Norbert, J., Roberts., Juan, C., Sarria. “4. Recognizing the Roles of Fever in Host Survival and in Medical Intervention in Infectious Diseases..” The American Journal of the Medical Sciences, (2024). doi: 10.1016/j.amjms.2024.05.013.
  9. https://www.aap.org/
  10. Tahir, Hameed., Sereen, AlMadani., Walaa, Shahin., Husam, Ardah., Walaa, A, Almaghrabi., Mohammed, Alhabdan., Ahmed, Mohammed, Alfaidi., Asma, Abuthamerah., Mamdouh, Al‐Ahmadi., Majed, Almalki., Mona, Al-Dabbagh. “1. Application of the Pecarn Prediction Rule for Febrile Infants up to 90 Days of Age: A Multi- Center Study. doi: 10.21203/rs.3.rs-4761730/v1.
  11. Natalia, Sutiman., Zi, Xean, Khoo., Gene, Yong-Kwang, Ong., Rupini, Piragasam., Shu-Ling, Chong. “2. Validation and comparison of the PECARN rule, Step-by-Step approach and Lab-score for predicting serious and invasive bacterial infections in young febril. e infants..” Annals Academy of Medicine Singapore (2022). doi: 10.47102/annals-acadmedsg.2022193.
  12. Stacy, Lund., Tine, Brink, Henriksen., Anja, Poulsen., Kia, Hee, Schultz, Dungu., Emma, Louise, Malchau, Carlsen., Bo, Mølholm, Hansen., Lise, Aunsholt., Ulrikka, Nygaard. “1. [Herpes simplex virus infection in newborns]..” Ugeskrift for Læger, 2022.
  13. Pantell RH, Roberts KB, Adams WG, et al. Evaluation and Management of Well-Appearing Febrile Infants 8 to 60 Days Old [published correction appears in Pediatrics. 2021 Nov;148(5):e2021054063. doi: 10.1542/peds.2021-054063]. Pediatrics. 2021;148(2):e2021052228. doi:10.1542/peds.2021-052228
  14. Rajendra, Prasad, Anne., Sourabh, Dutta., Haribalakrishna, Balasubramanian., Ashutosh, N., Aggarwal., Neelima, Chadha., Praveen, Kumar. “2. Meta-analysis of Cerebrospinal Fluid Cell Count and Biochemistry to Diagnose Meningitis in Infants Aged < 90 Days.”. American Journal of Perinatology. (2024), doi: 10.1055/a-2095-6729.
  15. Jamie, M., Pinto., Vaidehi, Patel., Anna, Petrova. “Role of viral pathogen(s) detection in hospital-based management of 29-90-day-old infants with unexplained fever..” MINERVA Pediatrica. (2023). doi: 10.23736/S2724-5276.23.07207-5.
  16. Rachel, G., Greenberg., Tamara, I., Herrera. “4. When to Perform Lumbar Puncture in Infants at Risk for Meningitis in the Neonatal Intensive Care Unit.” (2019). doi: 10.1016/B978-0-323-54391-0.00008-4.
  17. Dana, M., Foradori., Michelle, A., Lopez., Matthew, Hall., Andrea, T., Cruz., Jessica, L., Markham., Jeffrey, D., Colvin., Jennifer, A., Nead., Mary, Ann, Queen., Jean, L., Raphael., Sowdhamini, S., Wallace. “2. Invasive Bacterial Infections in Infants Yo. unger Than 60 Days With Skin and Soft Tissue Infections. Pediatric Emergency Care, doi: 10.1097/PEC.0000000000001584.
  18. Sandra, Trapani., Adele, Fiordelisi., Mariangela, Stinco., Massimo, Resti. “1. Update on Fever of Unknown Origin in Children: Focus on Etiologies and Clinical Approach.” Children (Basel), (2023). doi: 10.3390/children11010020.

Reviewed and Edited By

Picture of Jonathan Liow

Jonathan Liow

Jonathan conducts healthcare research in the Emergency Department at Tan Tock Seng Hospital. A graduate of the University at Buffalo with a BA in Psychology and Communication, he initially worked on breast cancer research studies at GIS A*STAR. His research interests focus on integrating AI into healthcare and adopting a multifaceted approach to patient care. In his free time, Jonathan enjoys photography, astronomy, and exploring nature as he seeks to understand our place in the universe. He is also passionate about sports, particularly badminton and football.

Picture of James Kwan

James Kwan

James Kwan is the Vice Chair of the Finance Committee for IFEM and a Senior Consultant in the Department of Emergency Medicine at Tan Tock Seng Hospital in Singapore. He holds academic appointments at the Lee Kong Chian School of Medicine, Nanyang Technological University, and the Yong Loo Lin School of Medicine, National University of Singapore. Before relocating to Singapore in 2016, James served as the Academic Head of Emergency Medicine and Lead in Assessment at Western Sydney University's School of Medicine in Australia. Passionate about medical education, he has spearheaded curriculum development for undergraduate and postgraduate programs at both national and international levels. His educational interests focus on assessment and entrustable professional activities, while his clinical expertise includes disaster medicine and trauma management.

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

Gastroenteritis and Dehydration In Children (2024)

~ iEM Education Project Team ~ Leave a comment

by Neha Hudlikar & Abdulla Alhmoudi 

Authors
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You have a new patient!

14-month-old Zoey is brought to A&E by her mother with complaints of vomiting and diarrhea for one day. She has had six episodes of vomiting and eight episodes of loose stools since last night. She has also not had a wet diaper for almost 12 hours now. In triage, her vitals are HR 165 b/min, RR 45 br/min, Temperature 38.5 C, SpO2 97% CR 3 seconds. The nurse in triage notes that she has a glazed look. She is otherwise fit and well, with no past medical history. Zoey’s weight – 10 kg.

What will be your approach for this patient?

a-photo-of-a-baby (image produced by using ideogram2.0)

What do you need to know?

Importance

Acute gastroenteritis is one of the most common reasons for visits to pediatric emergency departments [1]. The World Health Organization (WHO) defines diarrhea as the passage of three or more liquid stools per day, or a more frequent passage than what is normal for the individual. When diarrhea occurs alongside vomiting, it is referred to as acute gastroenteritis (AGE).

Diarrhea can be categorized into three clinical types based on the presence or absence of blood and the timing of symptoms:

1. Acute watery diarrhea – lasts from hours to several days, but less than 14 days.
2. Acute bloody diarrhea – also known as dysentery, lasts less than 14 days.
3. Persistent diarrhea – lasts longer than 14 days.

Infectious gastroenteritis can be caused by various pathogens, including viruses, bacteria, and parasites. Rotavirus is the most common causative agent worldwide, responsible for 37% of diarrhea-related deaths in children under five years of age.

Epidemiology

Gastroenteritis is the second leading cause of death in children below the age of 5 and a leading cause of malnutrition in this age group. Globally, there are approximately 1.7 billion cases of childhood diarrheal diseases yearly, and the burden is substantial [2]. There is a direct impact of admission costs on the hospital budget and direct and indirect societal costs when children are admitted to hospitals.

In low-income countries, children under three years old, on average, have three episodes of diarrhea every year. This puts them at risk of malnutrition and, in turn, makes them vulnerable to further episodes of infectious diarrhea.

Pathophysiology

The loss of water and electrolytes via stools, vomit, sweat, and urine without adequate replacement leads to dehydration, a serious complication of gastroenteritis. Physiologic factors that predispose children to serious complications from dehydration include limited stores of fat and glycogen, relatively larger extracellular fluid compartments, and a limited ability to conserve water through their kidneys compared to adults.

Bicarbonate loss in stools, decreased tissue perfusion leading to anaerobic metabolism and lactic acid production, ketosis due to starvation, and decreased excretion of hydrogen ions due to poor renal perfusion are some of the mechanisms contributing to metabolic acidosis in pediatric dehydration due to acute gastroenteritis.

The exact pathophysiology depends on the causative agent. Infectious agents cause diarrhea via adherence, mucosal invasion, enterotoxin, and cytotoxin production.S. aureus and Bacillus cereus produce heat-stable enterotoxins in the food, which once consumed, lead to rapid onset of symptoms and are usually self-limiting. C. Perfingens, Enterotoxigenic E.coli produce enterotoxins in the small intestine leading to watery diarrhea. Other pathogens like enterohemorrhagic E. Coli (EHEC), Salmonella, Shigella, and Campylobacter jejuni produce toxins that directly invade the bowel leading to inflammatory diarrhea. Viruses often destroy the villus surface of the intestinal mucosa, and parasites often adhere to the mucosa.

Medical History

A focused and detailed history is essential to narrowing our differential diagnoses and guiding management. The history should include the timing, frequency, and severity of symptoms. We should also ask about any contact with someone with similar symptoms, known or suspected outbreaks in school or nursery, and recent travel.

All patients with acute gastroenteritis are at risk of dehydration, and the initial evaluation should include questions to assess its severity. The child’s oral intake, amount of urine passed, mental status (lethargy/irritability), etc., should be asked for in the initial evaluation. 

It is also important to ask for associated symptoms such as fever, abdominal pain, blood in the stools, and rash. Children with inflammatory diarrhea can develop serious illnesses like hemolytic uremic syndrome (HUS) with renal involvement. 

Other important questions in history include the child’s vaccination status, recent hospitalization/antibiotic use, and whether the child has any underlying chronic medical conditions/immunosuppression.

Physical Examination

Examining the child should be systematic, looking for the severity of dehydration and differentiating gastroenteritis from other causes of vomiting and diarrhea in children.

General examination should include the child’s appearance, alertness, lethargy, irritability, and weight. Vital signs should be assessed relative to the age. Physicians should look for explicit signs of dehydration, such as dry mucous membranes, sunken eyes, depressed fontanelle, and the presence/absence of tears. The cardiovascular exam should include heart rate, quality of pulses, and central and peripheral capillary refill times. Deep, acidotic breathing suggests severe dehydration. An abdominal examination assesses tenderness, bowel sounds, guarding, and rebound. Flank tenderness increases the likelihood of pyelonephritis. Examine the skin to check skin turgor, peripheral temperature, and other signs such as jaundice/rash.

Abnormal skin turgor, prolonged capillary refill time, and abnormal respiratory pattern are the three most useful examination findings in children with more than 5% dehydration [3]. It is important to note that these signs can be subtle, and determining the severity of dehydration accurately is challenging for physicians.

Alternative Diagnoses

Dehydration most commonly results from acute gastroenteritis in children. However, other diagnoses should be considered based on physical examination and history. Children with fever who are very ill-looking should have sepsis as one of the differential diagnoses. Other diagnoses to consider are urinary tract infection, appendicitis, hemolytic uremic syndrome, intussusception, and diabetic ketoacidosis. Symptoms immediately after ingestion should prompt physicians to consider ingestion of a foreign body or toxic substance. 

Vomiting and diarrhea are two important components that ED practitioners need a careful evaluation to rule in or out various diseases.

When evaluating vomiting in children, it is essential to consider a wide range of differential diagnoses spanning several systems. Central nervous system causes include space-occupying lesions, hydrocephalus, and infections. Cardiac-related vomiting may be attributed to congestive heart failure from various etiologies. Gastrointestinal conditions such as intussusception, midgut volvulus, pyloric stenosis, appendicitis, and esophageal or hepatic disorders are significant considerations. Renal issues like urinary tract infections, pyelonephritis, renal insufficiency, and renal tubular acidosis can also manifest as vomiting. Furthermore, metabolic and endocrine abnormalities, including diabetic ketoacidosis, Addisonian crisis, congenital adrenal hyperplasia, and inborn errors of metabolism, are key causes. Infectious conditions such as sepsis, pneumonia, otitis media, streptococcal pharyngitis, and gastroenteritis must also be included in the diagnostic workup.

Diarrhea in children can arise from diverse causes. Gastrointestinal disorders such as intussusception, Hirschsprung’s disease with toxic megacolon, inflammatory bowel disease, and appendicitis are prominent. Renal conditions, including urinary tract infections and pyelonephritis, can also lead to diarrhea. Infectious etiologies like sepsis, pneumonia, gastroenteritis, and pseudomembranous colitis are frequent contributors. Other causes include drug effects or overdose, hemolytic uremic syndrome, and congenital secretory diarrhea.

Understanding these potential causes is essential for accurate diagnosis and effective management.

Acing Diagnostic Testing

The workup should be guided by history and physical examination to determine the level of dehydration. In most cases, it is a self-limiting disease, and the principal goal of testing in ED should be to identify and correct fluid, electrolyte, and acid-base deficits. 

Most children with mild to moderate disease require no diagnostic testing. Children requiring IV hydration should have blood gas, serum electrolytes, bicarbonate, urea, and creatinine levels tested. It is common for young children to have hypoglycemia, and checking serum glucose levels is important. In children presenting with fever or mucous/blood in their stools, consider testing for fecal leucocytes to support a diagnosis of invasive diarrhea. A positive test should be followed by a stool culture, and it is important to note that a negative test does not rule out invasive disease.

Consider additional testing, such as blood and urine cultures, chest X-rays, and lumbar puncture, in immunosuppressed patients, infants less than 2 months old, or children with suspicion of bacteremia or localized invasive disease. 

Risk Stratification

The Gorelick scale and The Clinical Dehydration Score (CDS) are two of the most widely used scoring systems to predict the presence and severity of dehydration in the pediatric population. It is important to note that neither can definitively rule in or out dehydration in children and infants. Physicians should continue to use a structured approach to patients presenting with acute gastroenteritis and use these scores to aid clinical decision-making [4,5,6].

Clinical Dehydration Scale

 

0

1

2

 

0: No dehydration (<3%)

1-4: Some dehydration (≥3%- <6%)

5-8: Moderate dehydration (≥6%)

General appearance

Normal

Thirsty, restless or lethargic but irritable when touched

Drowsy, limp, or comatose

Eyes

Normal

Slightly sunken

Very sunken

Mucous membranes

Moist

“Sticky”

Dry

Tears

Present

Decreased

Absent

 

Gorelick Scale for Dehydration

characteristic

no or minimal dehydration

moderate to severe dehydration

general appearance

alert

restless, lethargic, unconscious

capillary refill

normal

prolonged or minimal

tears

present

absent

mucous membrane

moist

dry, very dry

eyes

normal

sunken; deeply sunken

breathing

present

deep; deep and rapid

quality of pulses

normal

thready; weak or impalpable

skin elasticity

instant recoil

recoil slowly; recoil > 2 s

heart rate

normal

tachycardia

urine output

normal

reduced; not passed in many hours

Evaluating dehydration with Gorelick scale [6];

4-Point Scale (Italics):

  • 4 points: Presence of 2 or more clinical signs correlating with ≥5% body weight loss from baseline.
  • 4 points: Presence of 3 or more clinical signs correlating with ≥10% body weight loss from baseline.

10-Point Scale (Based on All Signs and Symptoms):

  • ≥3 clinical signs: Associated with ≥5% body weight loss from baseline.
  • ≥7 clinical signs: Associated with ≥10% body weight loss from baseline

Some groups are at higher risk of developing complications from acute gastroenteritis. These include premature infants, very low birth weight infants, and infants below the age of 3 months. Children who are malnourished, immunosuppressed, and with chronic underlying medical conditions are also at higher risk of developing complications.

Indications for inpatient management of children presenting with acute diarrhea have been proposed, and the Table below summarizes these recommendations.

Indications for Inpatient Management of Children with Acute Diarrhoea

  • Difficulties in administrating oral rehydration therapy (patient refusal, intractable vomiting)
  • History of premature birth, chronic medical conditions, or concurrent illness, very young age
  • Parental/caregiver concern about continuing ORT at home/unable to provide adequate care
  • Persistent vomiting, high output diarrhoea, persistent dehydration
  • Uncertainty of diagnosis warranting further observation
  • Progressive symptoms or unusual irritability/drowsiness
  • Lack of easy access to hospital care if needing to return

Adapted from King CK, Glass R, Bresee JS, Duggan C; Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003;52(RR-16):1-16.

Management

Management in the Emergency Department should initially focus on correcting dehydration. Oral rehydration solution (ORS) is recommended for all children with mild to moderate dehydration.

To calculate the volume of oral replacement therapy (ORT), the first step is to estimate the degree of dehydration based on history and physical examination findings (see Table below). The desired volume of ORS is then calculated based on the degree of dehydration (30 to 50 mL/kg for mild and 60 to 80 mL/kg for moderate dehydration). 25% of the calculated volume of ORS is given every hour for the first four hours and ongoing losses can be replaced at 10 mL/kg for each stool and 2 mL/kg for each emesis. The patient needs reassessment at the end of the first few hours and those with no clinical deterioration may have a 2 to 4-hour trial with ORT. If the child is unable to keep up with ongoing losses and if volume replacement is not adequate at the end of 8 hours, IV rehydration is recommended. Ondansetron is a selective 5-hydroxytryptamine type 3 receptor antagonist, a useful adjunct in treating AGE. It acts on peripheral and central chemoreceptors to alleviate nausea. It has been shown to decrease vomiting, improve oral intake, and reduce the need for intravenous fluid resuscitation and hospital admissions [7].

Assessment of Degree of Dehydration

Mild dehydration (3%-5%)

Moderate dehydration (5%-10%)

Severe dehydration (> 10%)

Mental status

Alert

Irritable

Lethargy

Heart rate

Normal

Increased

Increased

Quality of pulses

Normal

Normal to decreased

Decreased to thready

Mucous membranes

Wet

Slightly dry

Dry

Capillary refill

< 2 seconds

> 2 seconds

> 2 seconds

Blood pressure

Normal

Normal

Normal to decreased

Respirations

Normal

Tacypnea

Tachypnea, deep

Fontanelle

Normal

Sunken

Sunken

Eyes

Normal

Slightly sunken, decreased tears

Sunken, cries without tears

Urine output

Normal to decreased

Decreased

Oliguric or anuric

Skin turgor

Normal

Slightly reduced

Reduced

Children with severe dehydration, signs of shock, failed attempts with oral rehydration therapy, intractable vomiting, hypoglycemia, or electrolyte derangements require intravenous fluid resuscitation, which is often initiated as a 20 mL/kg bolus of 0.9% of sodium chloride in ED. These patients need frequent re-evaluation to review their response to IV hydration. Improvements in mental status, tachycardia, capillary refill time, and urine production are some signs that signal a good response to intravenous resuscitation. After initial resuscitation, patients will need an evaluation of their maintenance fluid needs, which could be either intravenous fluid therapy or ORT, depending on the patient’s clinical status. Maintenance fluids are calculated based on the child’s weight using the 4-2-1 Holliday-Segar Rule.

Holliday-Segar Rule for Maintenance Fluid Calculation

Body Weight

mL/kg/hr

mL/kg/day

First 10 kg

4

100

Second 10 kg

2

50

Each additional kg

1

20

Children who require multiple fluid boluses without signs of improvement should be investigated for other serious conditions such as adrenal insufficiency, cardiogenic or septic shock, etc. It is important to note that rapid correction of serum sodium levels can lead to osmotic demyelination syndrome in hyponatremia and cerebral edema in hypernatremia.

In children with hypoglycemia, glucose can be replaced as per the “rule of 50,” where the percent dextrose multiplied by the number of mL per kilogram equals 50. Neonates often get 10% dextrose solution at 5mL/kg, children between 1 month to 8 years of age (or 25 kg weight) can be given 2mL/kg of 25% dextrose. 50% of dextrose at 1mL/kg can be used safely in older children. The higher tonicity of 25% and 50% dextrose solutions poses a risk of tissue necrosis if extravasation occurs during peripheral IV infusion.
 
Antibiotics are not indicated in viral gastroenteritis and most cases of uncomplicated bacterial gastroenteritis. Considerations can be made for very young infants, immunocompromised, and those with chronic underlying medical conditions. The WHO recommends zinc supplementation for children under 5 years suffering from AGE in developing countries [8]. Studies showing the efficacy of probiotics are inconclusive and further research is needed to establish the safety and efficacy of probiotics in children with AGE [9].

When To Admit This Patient

Most cases of AGE are self-limiting and can be managed on an outpatient basis after a brief period of observation in the ED. Parents and caregivers should be given appropriate discharge instructions emphasizing hygiene and hand-washing techniques to prevent the further spread of the illness. Breastfeeding/routine diet should be continued at home, and supplemental electrolyte solutions may be recommended. Parents and caregivers should be educated to recognize the signs of dehydration and advised to bring the child back to the ED for these. Children with intractable vomiting, severe dehydration, failure to maintain oral hydration, electrolyte derangements, deteriorating clinical status, and those at high risk for complications (very low birth weight infants, < 3 months old, immunosuppressed, and children with chronic medical problems) should be admitted to hospital.

Revisiting Your Patient

History-taking reveals that Zoey has not had much to drink or eat in the past 12 hours, and there has been an outbreak of gastroenteritis in the nursery that she attends. There has been no blood in the stools, and Mum says that Zoey has been very sleepy for the last few hours. Her vaccinations are up to date, and she has no other medical history of note.

On examination, she is irritable when you approach her, and your systematic examination reveals the following:
CNS – Irritable, no signs of meningism, anterior fontanelle closed
HEENT – Dry mucous membranes, slightly sunken eyeballs
Respiratory – Mild tachypnea, bilateral air entry with clear breath sounds
CVS – Central capillary refill 3 seconds, tachycardia, BP 88/50
Abdomen – Soft, lax and non-tender. Bowel sounds ++, no mass palpable
Skin – Slightly reduced skin turgor, no rash

Next steps?

Your examination reveals no red flags of meningitis/sepsis or surgical abdomen. Given the recent outbreak of gastroenteritis in her nursery, you make a provisional diagnosis of acute gastroenteritis for Zoey. Your clinical assessment estimates the degree of dehydration to be moderate (5-10%), and you calculate her fluid depletion to be between 600 to 800 mL (60 to 80 mL/kg). You start the patient on oral rehydration therapy aiming for at least 200 mL to be given slowly over the next hour. You guide the mother in letting the staff know if Zoey vomits or has another episode of diarrhea while in the Emergency Department.

Investigations?

You ask for a random blood sugar to rule out hypoglycemia and a urine dipstick to rule out urinary tract infection.

Review
After an hour, Zoey tolerated 250 mL of oral rehydration solution and had one episode of vomiting but no diarrhea. Her blood sugar was 4 mmol/l. She has perked up significantly and is more alert than before. Her vital signs show improvement, and you decide to give her Ondansetron and continue the ORT.

After two hours, Zoey has tolerated around 400 mL of ORS and is more alert and interactive now. Her vitals are normal, and she has not had any further episodes of diarrhea or vomiting. She has also passed some urine, which has been tested and found to be negative for infection.

Mum was advised to continue oral hydration at home as well as the slow introduction of a regular diet and to come back to ED if Zoey could not tolerate orally, had intractable vomiting, any blood in her stools, high-grade fever, or change from her baseline mental status. Zoey was discharged from the ED and would follow up with her primary physician in the community.

Authors

Picture of Neha Hudlikar

Neha Hudlikar

Emergency Department, Zayed Military Hospital, Abu Dhabi

Picture of Abdulla Alhmoudi

Abdulla Alhmoudi

Dr Abdulla Alhmoudi is a Consultant Emergency Medicine, serving at Zayed Military Hospital and Sheikh Shakhbout Medical City - Abu Dhabi. He pursued his residency training in Emergency Medicine at George Washington University in Washington DC and further enhanced his expertise with a Fellowship in Extreme Environmental Medicine. Dr Alhmoudi's passion for medical education is evident in his professional pursuits. He currently holds the position of Associate Program Director at ZMH EM program and is a lecturer at Khalifa University College of Medicine and Health Sciences. Beyond medical education, he maintains a keen interest in military medicine and wilderness medicine.

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References

  1. McDermott KW, Stocks C, Freeman WJ. Overview of Pediatric Emergency Department Visits, 2015. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville (MD): Agency for Healthcare Research and Quality (US); August 7, 2018.
  2. Hartman RM, Cohen AL, Antoni S, et al. Risk Factors for Mortality Among Children Younger Than Age 5 Years With Severe Diarrhea in Low- and Middle-income Countries: Findings From the World Health Organization-coordinated Global Rotavirus and Pediatric Diarrhea Surveillance Networks [published correction appears in Clin Infect Dis. 2023 Jan 6;76(1):183]. Clin Infect Dis. 2023;76(3):e1047-e1053. doi:10.1093/cid/ciac561
  3. Steiner MJ, DeWalt DA, Byerley JS. Is this child dehydrated?. JAMA. 2004;291(22):2746-2754. doi:10.1001/jama.291.22.2746
  4. Falszewska A, Szajewska H, Dziechciarz P. Diagnostic accuracy of three clinical dehydration scales: a systematic review. Arch Dis Child. 2018;103(4):383-388. doi:10.1136/archdischild-2017-313762
  5. Freedman SB, Vandermeer B, Milne A, Hartling L; Pediatric Emergency Research Canada Gastroenteritis Study Group.
  6. Pringle K, Shah SP, Umulisa I, et al. Comparing the accuracy of the three popular clinical dehydration scales in children with diarrhea. Int J Emerg Med. 2011;4:58. Published 2011 Sep 9. doi:10.1186/1865-1380-4-58
  7. Tomasik E, Ziółkowska E, Kołodziej M, Szajewska H. Systematic review with meta-analysis: ondansetron for vomiting in children with acute gastroenteritis. Aliment Pharmacol Ther. 2016;44(5):438-446. doi:10.1111/apt.13728Diagnosing clinically significant dehydration in children with acute gastroenteritis using noninvasive methods: a meta-analysis. J Pediatr. 2015;166(4):908-16.e166. doi:10.1016/j.jpeds.2014.12.029
  8. Goldman RD. Zinc supplementation for acute gastroenteritis. Can Fam Physician. 2013;59(4):363-364.
  9. Cameron D, Hock QS, Kadim M, et al. Probiotics for gastrointestinal disorders: Proposed recommendations for children of the Asia-Pacific region. World J Gastroenterol. 2017;23(45):7952-7964. doi:10.3748/wjg.v23.i45.7952

Additional Resources

King CK, Glass R, Bresee JS, Duggan C; Centers for Disease Control and Prevention. Managing acute gastroenteritis among children: oral rehydration, maintenance, and nutritional therapy. MMWR Recomm Rep. 2003;52(RR-16):1-16.

Reviewed and Edited By

Picture of Arif Alper Cevik, MD, FEMAT, FIFEM

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

More dehydration content on iem-student.org

iEM Image Feed: Radius and Ulna Fracture

iem image feed radius and ulna fracture
~ iEM Education Project Team ~ Leave a comment
radius and ulna fracture

Her father brought a 9-year-old girl due to deformed right extremity. He was playing at home and fell from a hight on his hand. No open wounds. No past medical and surgical. Vaccination: up to date.

Examination: radial pulse is intact. He can move the fingers but with limitation due to pain. Sensation is normal. The X-ray showed both radius and ulna fracture. The patient underwent procedural sedation with IV ketamine, and the reduction was made with ortho oncall.

[cite]

Recognising Child Maltreatment and Steps to Safeguarding Children and Young People in the Emergency Department

recognizing child maltreatment
~ Nadine Schottler, Great Britain ~ Leave a comment

Safeguarding Children and Young People

In the busy and stressful environment of the emergency department (ED), it is often easy for us to miss the inexplicit signs or calls for help from children and young people! When looking at it from a broader view, the paediatric population is sometimes a part of the category of vulnerable patients who cannot ask for help, and may at times not realise they need it. Of the millions of children that pay visits to the ED a year, some present with non-accidental or non-intentional illnesses that had been brought upon by abuse or neglect. The ED can often be the first contact these children have with healthcare professionals, making it imperative that we notice the faint signs of maltreatment that may direct us towards acting for their protection.

The term safeguarding, as described by the government document, Working Together, encompasses the act of protecting children and young people from maltreatment, ensuring children and young people are growing up in a safe and healthy environment, and ensuring the best outcomes for all children and young people.

Who’s at Risk?

Parental issues, including alcohol/substance misuse, mental health problems, and domestic abuse, can indicate an unsafe environment for children. Additionally, poverty, poor housing, poor relationships with carers/parents, and a lack of support for the child can increase the risk of child maltreatment. Babies and disabled children are at an even greater risk of physical abuse.

Whose Responsibility is it to Protect and Safeguard Children and Young People?

According to various legislations, including the Children Act 2004, all healthcare staff and organisations must respond in times of suspected child maltreatment and take effective action to safeguard and protect these children. All healthcare staff should be prepared to amend their practice into a child-focused approach if there is any recognition of the risk of abuse or neglect in a child.

All NHS Trusts will have a specifically allocated doctor or nurse for safeguarding. Make sure to know who this is; they will be your point of contact if you have any concerns on safeguarding and child protection issues! This named healthcare professional will have the expertise to advise other professionals on the appropriate action to take.

What to do if a child reveals abuse:

  • Listen attentively
  • Let them know they have done the right thing by telling you
  • Tell them it is not their fault
  • Tell them you take them seriously
  • Do not confront the alleged abuser
  • Explain what you will do next
  • Report what the child has told you as soon as possible

Recognising Maltreatment

There are many forms of maltreatment a child may suffer from, including physical, emotional and mental. Many of these signs and symptoms don’t always point towards maltreatment immediately. The background history and presentation of the child will often be key to identifying issues. However, it may be worth considering child maltreatment if you notice the following:
 
  • A child that regularly has injuries (– check their records!)
  • Previous or current involvement with Children Social Care
  • The pattern of injury doesn’t make sense or match the history/explanation
  • A delay in seeking medical help (without appropriate explanation)
  • If the parent/carer leaves with the child before they are seen at the ED
      • Although there may be credible reasons for this, the Trust was responsible for ensuring all children in their care have a safe discharge. If the child leaves without the staff having been informed, action is required to ensure their safety.
  • Child missing appointments
  • Child not being registered with a GP

Physical symptoms of abuse:

  • Bruises/Swelling
  • Burns or scalds
  • Bite marks
  • Broke or fractured bones
  • Scarring
  • Signs of poisoning (vomiting, drowsiness, seizures)
  • Difficulty breathing  (as a result of drowning, suffocation, poison)
  • Evidence of neglect (unkempt, malnourished, smelly, dirty) 

Behavioural symptoms of abuse:

  • Anti-social behaviour
  • Anxiety, depression, suicidal thoughts
  • Drug/alcohol use
  • Eating disorders
  • Aggression/Tantrums
  • Bed-wetting, insomnia
  • Problems in school (slow development)

Next Steps if Maltreatment is Suspected

When abuse is suspected, a referral to social care must be made within 24 hours (the sooner, the better). Make sure records are kept! The child will have registered with the reception staff and given their demographics, but it is important that he child’s GP and school details are in the system, as well as recording the details and relationship of the person(s) accompanying the child. Have a look through previous history/attendances for any potential indicators of reoccurring/previous child maltreatment.

To prepare for making a social care referral, first discuss the concerns with a senior staff member in the ED. Ensure some of the indicators of child maltreatment (such as those listed above) are present to support the referral decision. Consider previous information available about the child that is relevant (such as those on previous medical attendances). The child’s demographics should be known and recorded, and then contact the Local authority of the area the child normally resides to see if the child is subjected to a child protection plan or maybe previously known to children’s care services. Carry out any relevant lateral checks (GP, school nurse, etc.) Consider looking at the Trust’s local Thresholds for referral document before continuing to make the referral. If any further advice is needed, the safeguarding team can be contacted.

Children presenting with self-harm or suicidal issues
Children (ages 0-16) should be referred to a paediatrician/child psychiatrist if they present with thoughts or acts of self-harm or suicide. Trust guidelines on dealing with self-harm in children 16 years and under are available at your local Trust, as well as by NICE guidelines. All children (aged 0-18) presenting with substance misuse issues or emotional issues should be further referred to CAMHS.

Upon discharge, all children should be given the appropriate resources within the department so they know who to contact for support or further information (this could include leaflets, phone numbers, etc.)

Safeguarding Children and the Data Protection Act 1998

The law permits the disclosure of confidential information when necessary to safeguard a child. Personal information (about the child or family) is confidential. Healthcare professionals are subjected to a legal duty of confidence. However, information that is relevant, pertinent, and justified in the child’s interest may be disclosed without consent.

References and Further Reading

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Recent Blog Posts by Nadine Schottler, Great Britain

Immediate Management of Paediatric Traumatic Brain Injury

~ Nadine Schottler, Great Britain ~ Leave a comment

Traumatic brain injury (TBI) has been noted as a leading cause of death and disability in infants, children, and adolescence (Araki, Yokota and Morita, 2017). In the UK alone, it’s approximated 1.4 million individuals attend the emergency department (ED) with head injury, and of those, 33%-50% are children under the age of 15; on top of this, a fifth of those patients admitted have features suggesting skull fracture or brain damage – that’s no small figure (NICE, 2014)! The particular importance of TBI in the paediatric population is that the treatment and management approach differs to adults; this is largely due to the anatomical and physiological differences in children. Furthermore, neurological evaluation in children proves more complex. All in all, children are complicated, and it is of great importance that we are aware of these differences when a paediatric patient arrives at the ED with TBI presentations.

Why is the paediatric population at risk for TBIs?

To delve slightly deeper into physiology and anatomy, there are several reasons children are at high risk of acquiring serious injury from TBIs. The paediatric brain has higher plasticity and deformity. As such, their less rigid skulls and open sutures allow for greater shock absorbance and response to mechanical stresses (Ghajar and Hariri, 1992). This ‘shaking’ of the brain inside the skull can stretch and tear at blood vessels in the brain parenchyma, resulting in cerebral haemorrhage.

Children also have a larger head-to-body size ratio, making the probability of head involvement in injury consequently higher (in comparison to adults); the head is also relatively heavier in a child, making it more vulnerable (especially in injury caused by sudden acceleration).

Young children have weaker neck muscles on top of having relatively heavier heads. Ligaments in the neck are relied on for craniocervical stability more so than the vertebrae. Hence, not only are TBIs more likely, but craniocervical junction lesions can also result from traumatic injury.

How does TBI in children come about?

The common causes of TBI in the paediatric population varies with age (Araki, Yokota and Morita, 2017). Some of these causes can be seen in the table below, which has been adopted from Araki, Yokota, and Morita (2017).

Table 1 Injury characteristics according to age and development

How can TBI in children present?

  • History: dangerous mechanism of injury (e.g. road traffic accidents or fall from a height greater than 1 meter)
  • Glasgow Coma Scale (GCS) less than 15 (at 2 hours after injury)
  • Visible bleeding, bruise, swelling, laceration
  • Signs of base-of-skull fracture:
    •  ‘Panda’ eyes – haemotympanum
    • Battle’s sign – cerebrospinal fluid leakage from ear or nose
  • Seizure (ask about history of epilepsy)
  • Focal neurological deficit
  • Vomiting
  • Loss of consciousness
  • Amnesia lasting more than 5 minutes
  • Abnormal drowsiness 

Note some children won’t have any of these signs, but if there is any suspicion of possible TBI, it should be investigated further.

Immediate management

There are various causes to paediatric TBI – also subdivided into primary and secondary TBI. Primary TBI includes skull fractures and intracranial injury. Secondary TBI can be caused by diffuse cerebral swelling. Primary and secondary TBI will be managed similarly in initial treatment (i.e. in the ED). The goal of baseline treatment is to:

  1. maintain blood flow to the brain
  2. prevent ischaemia (and possible secondary injury)
  3. maintain homeostasis 

Analgesia, Sedation, Seizure Prophylaxis

A level of anaesthesia needs to be achieved to allow for invasive procedures, such as airway management and intracranial pressure (ICP) control. Normally opioids and benzodiazepines are using in combination for analgesia and sedation in children. Instances where a child presents with a severe TBI (defined as a ‘brain injury resulting in a loss of consciousness of greater than 6 hours and a Glasgow Coma Scale of 3 to 8’), a neuromuscular block is used to improve mechanical ventilation, stop shivering, and reduce metabolic demand.

Anticonvulsants have been used in children, in particular infants, as they have a lower seizure threshold. Risk factors for early onset of seizures in infants under the age of 2 include hypotension, child abuse, and a GCS of ≤ 8; note, all of which may occur as a result of, or preceding, a TBI! For severe paediatric TBI cases, immediate prophylactic administration of anticonvulsants has been recommended.

Maintaining Cerebral Perfusion

The gold standard to measure ICP is an external ventricular drain (EVD); which can be used not only to measure ICP but can also be opened to drain additional CSF to reduce ICP. An intraparenchymal intracranial pressure sensor is an immediate invasive method used to detect early increased ICP in children with TBI. Monitoring of both ICP and cerebral perfusion pressure (CPP) is considered standard practice in TBI management in both paediatric and adult populations, as it is associated with better outcomes.

CPP is the pressure gradient which allows for cerebral blood flow. If this pressure is not maintained, the brain will lose adequate blood flow (Ness-Cochinwala and Dwarakanathan, 2019). Elevated CPP can accelerate oedema and increase chances of secondary intracranial hypertension.

Cerebral Perfusion Pressure (CPP) = Mean Arterial Pressure (MAP) – Intracranial Pressure (ICP)

A CPP of around 40-60 mmHg (40-50mmHg in 0-5 year-olds and 50-60mmHg in 6-17 year-olds) is considered ideal. Achieving an adequate CPP can be done by increasing MAP or reducing ICP (using the above equation). Hence it is necessary to have a good understanding of what good target values for MAP and ICP are.

A good target value for MAP is the upper end of ‘normal’ for the child’s age. Reaching this can be done by using fluids (if fluid deficient) or by use of inotropes. The recommended ICP target is < 20mmHg (normal is between 5-15 mmHg and raised ICP is regarded as values over 20mmHg).

When thinking about ICP, it’s useful to remember a mass in the brain; a mass being possible haemorrhage or any other space-occupying lesion. In TBI, oedema is most prominent at around 24-72 hours post-injury. As a result of increased mass, the initial consequence is a displacement of cerebrospinal fluid (CSF) into the spinal cord. Following this, venous blood in the cranium will also be displaced.

If ICP is further elevated, herniation can result – which is serious and often fatal! Signs of uncal herniation can present as unilateral fixed and dilated pupil. Signs of raised ICP can include pupillary dilatation and series of responses known as the ‘Cushing’s Triad’: irregular, decreased respiration (due to impaired brainstem function), bradycardia, and systolic hypertension (widened pulse pressure). Cushing’s triad results from the response of the body to overcome increased ICP by increasing arterial pressure.

Using the Monroe-Kellie Doctrine as a guide, we can predict how to reduce ICP. One management is head positioning. Head-of-bed should be elevated to 30˚, with the head in mid-line position, to encourage cerebral venous drainage. The EVD can also be used to drain CSF.

Commonly, intravenous mannitol and hypertonic saline are used to manage intracranial hypertension in TBI. Mannitol is traditionally used at a dosage of 20% at 0.25-1.0 g/kg – this is repeatedly administered. The plasma osmolality of the patient needs to be kept a close eye on; it should be ≤ 310 mOsm/L. 3% NaCl can be used to raise sodium levels to 140-150 mEg/L – this is slightly higher than normal sodium levels as a higher blood osmolarity will pull water out of neurons and brain cells osmotically and reduce cerebral oedema (Kochanek et al., 2019). Mannitol works in the same manner, however, use with caution as mannitol, being an osmotic diuretic, can cause blood pressure drops and compromise CPP! In last-resort emergency cases, where ICP need to be immediately reduced, a decompressive craniotomy can be performed.

Intravascular Volume Status

Measuring the patient’s central venous pressure (CVP) is a good indicator of the child’s volume status; 4-10 mmHg have been used as target thresholds. Alternatively, you can also monitor urine output (>1mL/kg/hr), blood urea nitrogen, and serum creatinine. Low volume status should be corrected with a fluid bolus. If the patient’s volume status is normal or high, but they remain hypotensive, vasopressors may improve blood pressure. At all costs, hypotension must be avoided, as if can lead to reduced cerebral perfusion and lead to brain ischaemia; on the other end, hypertension can cause severe cerebral oedema and should also be kept an eye on.

Other considerations​ - There have been reports of pituitary dysfunction in 25% of paediatric TBIs (during the acute phase). Do consider this if the patient had refractory hypotension – keep ACTH deficiency in mind!

Ischaemia

Prevent hypoxia at all costs! Hypoxia goes hand-in-hand with cerebral vasodilation – and as we already know, this increases the pressure in the cranium. Additionally, with hypoxia, there will be ischaemia. A minimum haemoglobin target of 7.0 g/dl is advised in a severe paediatric TBI case.

Other considerations​ - Whilst we are on the blood topic, also take care to correct and control any coagulopathies.

Ventilation

At a Paediatric Glasgow Coma Scale (PGCS) of less than 8, airways must be secured with a tracheal tube and mechanical ventilation commenced. SpO2 should be maintained at greater than 92%.

Of course, hypercapnia (CO2 > 6 kPa) and hypocapnia (CO2 < 4 kPa) are both not ideal, and we should maintain paCO2 at 4.5 – 5.3 kPa. However, some sources have suggested a quick fix to reduce ICP is to acutely hyperventilate the patient (as low CO2 results in cerebral vasoconstriction) – it’s suggested that paCO2 can safely go as low as 2.67 kPa before ischaemia kicks in! Mild hyperventilation is recommended (3.9 – 4.6 kPa)(Araki, Yokota and Morita, 2017).

Decreasing Metabolic Demand of the Brain

Body Temperature

What we want is to prevent hyperthermia, as it increases cerebral metabolic demands. Normothermia (36.5˚C – 37.5˚C) can be maintained by use of cooling blankets or antipyretics. There has been debate on whether therapeutic hypothermia has shown any benefit. Some studies have shown that moderate hypothermia for up to 48 hours, followed by slow rewarming, has prevented rebound intracranial hypertension as well as decreased ICP, however, there have not been any confirmed functional outcomes or decreased mortality rates benefits of this method (Adelson et al., 2013; Hutchinson et al., 2008).

Glycaemic control

Persistent hyperglycaemia (glucose > 10 mmol/L) should be treated. Hypoglycaemia (< 4 mmol/L) is much more dangerous. Persistent hyperglycaemia can be managed by reducing the dextrose concentration in IVF (which is usually administered in the first 48 hours of ICU care), or by starting an insulin drip.

A comment on imaging methods

In the UK, the initial investigation choice for detecting acute brain injuries is a CT head scan. A CT scan should be done within an hour of suspected head injury.
If there are no indications for a CT head scan (i.e. the signs/symptoms listed previously), a CT head scan should be performed within 8 hours of injury (NICE, 2014).

MRI scans are not usually done as the initial investigation, however, they have shown to provide information on the patient’s prognosis.

A final and most important note:

Don’t ever forget Safeguarding in children. Unfortunately, child maltreatment is common and can present anywhere. Have a look at the NICE guidelines below for more on how to identify child maltreatment.

Further reading

References

  • Adelson PD, Wisniewski SR, Beca J, Brown SD, Bell M, Muizelaar JP, Okada P, Beers SR, Balasubramani GK, Hirtz D; Paediatric Traumatic Brain Injury Consortium. Comparison of hypothermia and normothermia after severe traumatic brain injury in children (Cool Kids): a phase 3, randomised controlled trial. Lancet Neurol. 2013 Jun;12(6):546-53. doi: 10.1016/S1474-4422(13)70077-2.
  • Araki T, Yokota H, Morita A. Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management. Neurol Med Chir (Tokyo). 2017;57(2):82-93. doi:10.2176/nmc.ra.2016-0191
  • Finnegan R, Kehoe J, McMahon O, Donoghue V, Crimmins D, Caird J, Murphy J. Primary External Ventricular Drains in the Management of Open Myelomeningocele Repairs in the Neonatal Setting in Ireland. Ir Med J. 2019 May 9;112(5):930.
  • Ghajar J, Hariri RJ. Management of pediatric head injury. Pediatr Clin North Am. 1992;39(5):1093-1125. doi:10.1016/s0031-3955(16)38409-7
  • Hutchison JS, Ward RE, Lacroix J, Hébert PC, Barnes MA, Bohn DJ, Dirks PB, Doucette S, Fergusson D, Gottesman R, Joffe AR, Kirpalani HM, Meyer PG, Morris KP, Moher D, Singh RN, Skippen PW; Hypothermia Pediatric Head Injury Trial Investigators and the Canadian Critical Care Trials Group. Hypothermia therapy after traumatic brain injury in children. N Engl J Med. 2008 Jun 5;358(23):2447-56. doi: 10.1056/NEJMoa0706930.
  • Kochanek PM, Tasker RC, Bell MJ, Adelson PD, Carney N, Vavilala MS, Selden NR, Bratton SL, Grant GA, Kissoon N, Reuter-Rice KE, Wainwright MS. Management of Pediatric Severe Traumatic Brain Injury: 2019 Consensus and Guidelines-Based Algorithm for First and Second Tier Therapies. Pediatr Crit Care Med. 2019 Mar;20(3):269-279. doi: 10.1097/PCC.0000000000001737.
  • National Institute for Health and Care Excellence. Head injury: assessment and early management. 2014. Available at: https://www.nice.org.uk/guidance/cg176
  • Ness-Cochinwala M., Dwarakanathan D. Protecting #1 – Neuroprotective Strategies For Traumatic Brain Injury. Paediatric FOAMed. 2019. 
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The Kawasaki Disease Enigma Continues 150 years Later

kawasaki disease
~ Leah Sarah Peer, Canada ~ Leave a comment

Kawasaki disease (KD), or mucocutaneous lymph nodes syndrome is an immune-mediated inflammation in the walls of medium-sized arteries throughout the body. It’s complications result in the coronary arteries expanding, heart attacks, and premature death.

As the leading cause of heart disease in North American and Japanese children, KD continues to bewilder clinicians and researchers – even in the midst of a global pandemic. Possible links to SARS-CoV2 has even stirred uneasiness in patients, and physicians making diagnoses.

Beginning in Victorian-era England, a young boy presented to the doctor’s office with symptoms suggestive of scarlet fever; however, noticing heart disease in this child was just baffling. Despite being unaware of this rare disease, it was beyond physicians at the time; since then, progress has been limited as clinicians still fail to comprehend the disease’s root cause.

Dating back to 1874, KD was discovered by Samuel Gee while he was dissecting the cadaver of a seven-year-old boy.

He noticed something strange, “The pericardium was natural. The heart natural in size, and the valves healthy. The coronary arteries were dilated into aneurysms at three places, namely, at the apex of the heart a small aneurysm the size of a pea; at the base of the right ventricle, close to the tip of the right auricular appendix, and near to the mouth of one of the coronary arteries, another aneurysm of the same size; and at the back of the heart, at the base of the ventricles, and in the sulcus between the ventricles, a third aneurysm the size of a horse bean. These aneurysms contained small recent clots, quite loose. The aorta near the valves, and the aortic cusp of the mitral valve, presented specks of atheroma.”

From his autopsy, evident was that Gee found aneurysms in the coronary arteries running across the surface of the boy’s heart. He then placed the specimen in a jar and provided it to the Barts Pathology Museum in London. Little did he know, that his specimen marked evidence of the earliest recorded case of KD and sparked worldwide medical curiosity. Unfortunately, when physicians 100 years later were hoping to retrieve samples from the specimen containing the boy’s heart, they were informed that it was missing.

A few years later, the disease was recognized in 1967 by the Japanese physician, Tomikasu Kawasaki. Although some researchers claimed the virus was unknown, others stated KD resulted from a bacterial or fungal toxin. The windborne theory suggested that the disease was seasonal, and as such, the direction of the swaying wind played a role in infection. Others stated that since children’s immune systems are still developing and since they have just lost the protective antibodies from their mothers, they are susceptible to infection. Therefore, in Asian American household’s diets rich in soy put Asian children at greater risk due to the isoflavones. In the 1980s, the Center for Disease Control and Prevention (CDC) suspected chemicals as the cause of KD, inferring that disease stems from agents that trigger an overreaction of the patient’s immune system. No one knew exactly what the mechanism or cause of KD was, although many scientists speculated some theories.

Over the last decade, significant progress toward understanding the pathogenesis, history, and therapeutic interventions of KD has been fruitful. Treatment aimed at the intravenous infusion of gamma globulin antibodies derived from the plasma of blood donations has helped children recover. In contrast, other therapies of corticosteroids for immunoglobulin-resistant patients and tumor inhibitors such as etanercept, infliximab, and cyclosporin A have been other medications providing relief.

The most significant clinical debate was over the possible link between the rash and the cardiac complications seen in Asian American children. Factors responsible for KD were introduced into Japan after World War II and re-emerged in a more virulent form spreading through the industrialized Western world. Advancements in medicine, improvements in healthcare, and, notably, the use of antibiotics reduced the burden of rash and fever illnesses significantly allowing KD to be recognized as a distinct clinical entity.

Nonetheless, the enigma pervades even during the COVID19 pandemic; this time, more pressing as the ever-elusive cause of KD that troubles children’s hearts affects physicians’ sleep and worries parents’ minds. Although the story of Kawasaki disease began decades ago when a young boy’s heart was locked inside a glass specimen, its ending is still being crafted. By the time the heart is found again at the museum, and placed safely for visitors treasuring ancient history, what further knowledge and progress will the scientific community have achieved? How far will humanity have come to find answers to KD and fill in the perplexing missing piece of the puzzle?

For now, there are no answers, but the enigma continues…

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References and Further Reading

The Pediatric patient in the ED: Peculiar and Paramount

The Pediatric patient in the ED
~ Israa M Salih, UAE ~ 1 Comment

Children are not young adults!

This was the opening speech of the first Pediatrics lecture in my medical school.
As Emergency Physicians, we deal with everything and everyone at the same time; in some instances, the segmentation between types of patients blurs. The pediatric patient in the middle might be a challenge if you are not working in an independent Pediatrics Emergency Department.

In some situations, you will have to make decisions by conscious contemplation rather than pattern matching, which we mostly depend on in our approach.

Having had the privilege of working in an independent Pediatrics ED, I realized how much easier decision making becomes when you have a set of mind prepared to deal with a child.

Health problems for children differ from those of adults. A child’s response to disease and stress varies with age and development; therefore, it’s fundamental to approach children in a way that identifies and tackles the differences.

child response to disease

Judge by appearance

We use heuristics frequently in our practice, perhaps the most popular among which is the (sick/not sick) paradigm. When it comes to children, appearance is of particular importance.

The look might be deceptive in adults, but it’s not the case in children; as they say, the eyes don’t lie, but it can be lied to.

For its virtual implication, appearance represents the first component of the Pediatrics assessment triangle, our quick and orderly assessment tool for children.

Power and authority

Children can’t consent or advocate for themselves, a parent or legal guardian approval is required to deliver health care. The most notable exception to this is the emergency situation, in which consent is not required, and care can be delivered if parents are not present and even against their wishes. The emergency situation gives the emergency physician the highest authority in decision making in children, which is a titanic responsibility.

pediatric patient in the ed

The Math geek

Dosing for most medications in children is weight dependent. It might be good practice for your brain but can also represent a dilemma if you are giving verbal orders and your phone is not with you. My colleague once said I was terrible at Math; that’s why I went to medical school; I think she made a good point.

Baby shark

ED is a noisy environment, but the Pediatrics ED is on another level of noise. Other than natural sounds found in the ED and crying fussy children, you will also encounter countless children’s music and disturbing games. It might sound nihilistic and resentful, but I have to be forthright, the current children’s entertaining materials lack educational value and taste, and it needs resuscitation.

pediatric ed noise

Priceless outcome

In the end, the smile on a child’s face is one of the most satisfying experiences ever and a blessing. Establishing a rapport with a child is the key to a proper exam. Children won’t trust anything that’s not genuine, and care should be delivered with love and passion. You might also need to learn some tricks and give some treats to accomplish that, in the hope that you reach the fruitful outcome of drawing a smile on God’s angelic creatures.

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