Wound Care

Wound care is a common complaint in the pediatric emergency department, and depending on the type of wound, there are a myriad of options for treatment. Various options exist for analgesia and anxiolysis, including child-friendly techniques and topical, oral, intranasal, and injectable medications. Options for wound repair include nonsuture techniques, which may be favorable in children when appropriate (e.g., hair apposition technique and tissue adhesives). This chapter discusses types of wounds, analgesia, cleaning, repair of wounds (including topical adhesives, sutures, and staples), and tetanus prophylaxis. Suturing methods and various types of sutures with their respective indications are reviewed. It also discusses common complications and indications for antibiotic treatment, imaging, consultations, and disposition.

Oral and Dental Emergencies

Pediatric visits to the emergency department for oral and dental complaints are common and may be due to either traumatic or nontraumatic etiologies. Dental or oral–maxillofacial surgery consultants are often unavailable for acute emergency department evaluation. Fortunately, few dental and oral conditions require immediate intervention by a specialist, and basic principles may be applied to their triage and management. A fundamental understanding of the basic triage and management of dental and oral-related conditions, which is the focus of this chapter, is worthwhile for today’s emergency practitioner.

Emergency Pediatric Noninvasive Ventilation and Invasive Mechanical Ventilation

Respiratory complaints are common conditions for children to present to emergency departments. Typically, patients respond to simple supportive treatment, whether it is airway clearance therapy, oxygen therapy, or bronchodilators. When these patients are critically ill, they often require aggressive oxygenation/ventilation with noninvasive strategies, or even tracheal intubation. The use of noninvasive positive pressure ventilation has led to a significant reduction in the necessity for endotracheal intubation in children. The emergency physician should be familiar with the indications and appropriate application of these modalities. Furthermore, when patients require invasive mechanical ventilation, the emergency physician should have an understanding of initial ventilator settings, troubleshooting alarms, and an approach to the decompensating pediatric ventilated patient.

Neonatal Resuscitation

The majority of neonates born in the United States breathe spontaneously and do not require special assistance, but approximately 10% require some intervention, and less than 1% require extensive resuscitation measures. Although the number of infants delivered in the emergency department is unknown, out-of-hospital births have been increasing; thus, pediatric emergency physicians should be prepared for the possibility of a neonatal resuscitation in the emergency department. The acute resuscitation of the neonate should follow the Neonatal Resuscitation Program algorithm and includes assessment of heart rate, color, tone, and respiratory effort within the first minute of life. Initial treatment requires warming and gentle stimulation. Positive pressure ventilation should be initiated if the heart rate is <100 beats per minute, and chest compressions should be initiated if the heart rate is <60 beats per minute.

Pediatric Oncologic Emergencies

Children may present emergently with signs and symptoms concerning for an undiagnosed underlying malignancy or may present with life-threatening conditions related to a known malignancy or its therapy. Patients undergoing therapy for their cancer will have compromised immune systems and decreased function of vital organs from chemotherapeutic agent toxicity, sometimes resulting in diagnostic and therapeutic dilemmas and hastening their demise. This chapter reviews common presentations of several pediatric malignancies as well as complications that may arise during their therapy.

The Pediatric Chest X-Ray

The pediatric chest X-ray (CXR) provides a wealth of useful information. In most instances, clinicians are seeking more definitive information regarding the lungs. Findings can be subtle or obvious, but difficult to notice. “Tunnel vision” permits the human brain to focus on areas of interest, only to miss other important findings. This chapter discusses the clinical entities that can be identified on a pediatric CXR and presents examples of most of these entities. The CXR is best read in a methodical manner focusing one’s attention on the heart, lungs, aorta, mediastinum, bones, neck, abdomen, and the periphery of the CXR.

Fever in the Young Infant

Fever is the most common complaint of children who present to the emergency department. Approximately 12% of febrile neonates (aged 0–28 days) and young infants (aged 29—56 days) have serious bacterial infections (bacteremia, meningitis, urinary tract infections, pneumonia, bacterial gastroenteritis, and osteomyelitis). The evaluation and management of the febrile neonate and febrile young infant can be confusing. All febrile neonates require diagnostic testing, treatment with antibiotics, and hospital admission. The workup of the febrile young infant is more controversial. These patients should undergo blood and urine testing, but the need for lumbar puncture is controversial, as is the need for empiric antibiotic treatment. The disposition of these patients will depend on the results of these screening tests.

Pediatric Resuscitation

Respiratory failure is the most common cause of cardiopulmonary arrest in children. Early recognition of the critically ill child and aggressive management of respiratory failure and shock are crucial to preventing cardiopulmonary arrest. Although caring for a sick child can be highly stressful for emergency physicians, pediatric resuscitation largely mirrors that of adults, with special consideration of a few key anatomic and physiologic differences. It is important to have a systematic approach to patient assessment, medication dosing, and equipment sizing in order to cognitively offload the emergency provider. The following will help maximize performance in these high-stakes situations: the Pediatric Assessment Triangle combined with the familiar airway, breathing, circulation, disability, exposure approach; an age-, weight-, or length-based medication/equipment system; and routine application of Pediatric Advanced Life Support algorithms.

Renal Emergencies in Children

Renal emergencies in pediatric patients range from more common conditions such as urinary tract infections to rarer conditions such as hemolytic uremic syndrome. This chapter reviews emergency conditions that are less commonly seen, with potentially significant sequelae, and with possible nonspecific or more subtle presentations. Acute kidney injury can be due to a wide range of causes, including benign gastroenteritis and post-streptococcal or toxin-related causes. Less common but more serious conditions, such as nephrotic syndrome or Henoch–Schönlein purpura, present with nonspecific signs such as edema or rash. Acute glomerulonephritis needs to be considered in a child with a history of streptococcal pharyngitis or skin infection. Hemolytic uremic syndrome is typically Shiga toxin-related and should be considered in any ill-appearing child, especially those presenting with bloody stools. Disposition of a child with a renal emergency will depend on the severity of illness, laboratory results, and the ability to follow-up with their primary care provider or specialist.

Pediatric Thoraco-Abdominal Trauma

In children, injury is the most common cause of death. Thoracic and abdominal trauma are both associated with high morbidity and mortality, and they warrant a thorough evaluation. Abdominal trauma occurs in 25% of children with major trauma and is responsible for 9% of all trauma deaths. Because it can delay care, lack of recognition of intra-abdominal injury increases morbidity and mortality. Thoracic trauma comprises only 4–6% of pediatric trauma but is related to 14% of pediatric trauma-related deaths and is the second most common cause of mortality in pediatric trauma. This chapter discusses the keys to the evaluation of the pediatric trauma patient with thoraco-abdominal injury, including the evidence-based approach and algorithms to be utilized by medical personnel.