Acute COVID-19 in Children: A Primer for PEM Physicians

Francisco Gonzalez, MD and Noah Kondamudi, MD, MBA, FAAP, FACEP

This article is intended to be a brief primer about COVID-19 illness among children with a focus on emergency department management. For readers that would like more in depth information, we refer them to these recently published review articles [1, 2, 3]

So far, over 3.4 million cases of pediatric COVID-19 cases have been reported in the U.S for a prevalence of 4525/100,000 children, out of which approximately 0.1-2.2% resulted in hospitalization and 0.04% resulted in death4. As cases of SARS CoV-2 infections continue to overwhelm hospitals and emergency departments around the country, it is important for emergency physicians to recognize signs and symptoms of this disease, cohort cases to avoid endangering staff and other patients, distinguish which individuals require testing, and ultimately manage them appropriately. read more

Definitions and Debunking Drowning Myths

Chantel Mendes, MD and Jonathan Eisenberg, MD

In my 4th year of medical school, a boy drowned in the lake near my house. It was a shocking event at the time because my perception had been that drowning was a rare tragedy, more abundant and dramatized on television than in reality. However, during my training, I have learned that drowning remains a significant cause of death in children. Although mortality rates have been trending downward in recent years, CDC data from 2019 shows that drowning is still the leading cause of accidental injury death in children aged one to four and remains one of the top three leading causes of accidental injury death in children of all ages over one year. Children under the age of 14 account for one out of every five drowning deaths and there are approximately ten deaths per day due to drowning. It is important to note that these reported numbers relate to mortality rate alone and do not include morbidity from drowning such as neurological deficits or sequelae from a drowning event. The full extent of injury secondary to submersion is difficult to know as data gathering is challenging due to misinformation that persists surrounding drowning among the public, government agencies and even the medical community. read more

February 2021 Letter from the Section Chair

As I drove home from my last overnight shift in the emergency department, I was weary, eager to commence my “at-home” COVID-doffing routine. Annoyed, as each red light posed a barrier between me and sleep, I caught a glimpse of the majestic sunrise peeking over the horizon. I paused to take in the beauty and reflect on the parallel in my life. After persevering through the bleak “night” of 2020, many of us are weary, exhausted, and perhaps even a bit annoyed. But I encourage you to take a moment and reflect on the positive highlights of 2020, and express gratitude and hope for the new horizon that 2021 brings.

Among the many things I am grateful for, I am thankful for the support and camaraderie of the ACEP organization. While the Pediatric Section officers and I had different plans for 2020, supported by amazing members like yourselves, we were able to pivot and are proud of our accomplishments.

In April 2020, amidst all the uncertainty surrounding the novel coronavirus, the PEM section hosted a very informative webinar, COVID19: The Pediatric Perspective. It featured distinguished panelists from three regions (New York, Washington State, and California), which were highly impacted by the novel coronavirus. More than 300 attendees were present during the webinar, and a wide variety of topics were discussed.

Despite COVID-19’s preeminent position at the forefront of everyone’s minds, we still had to manage other common pediatric complaints in the Emergency Department. To provide ongoing, seasonally appropriate educational material, the microsite editors posted information about orthopedic trauma, caustic ingestions, and firecracker and blast injuries. You can find these and other great articles on our microsite: ACEP’s PEM Microsite | Quality Care for Kids Everywhere!

My simple, personal mantra on some of the darker days of 2020 was “I love my job!” And yes, we think PEM is a great specialty! The section officers wanted to support residents who were interested pursuing it as a career. As such, we hosted a webinar in early fall with PEM Fellowship program directors from varied institutions who answered key questions and provided sage advice to the many residents who attended the session. The discussion was so rich, we ran out of time! Check out a few excerpts from the Q &A at our twitter – @PedsACEP.

One of the highlights of my academic year has always been traveling to the annual ACEP Scientific Assembly. It is a time to catch up with dear friends, embrace new collaborations and learn information to aid my clinical practice. This year, “Unconventional” did not disappoint. If you missed the PEM section meeting, you missed a treat! We celebrated our E-Images winners (to be highlighted on our microsite soon—stay tuned!), did virtual yoga, and had engaging discussions on topics ranging from financial fitness to faculty development and networking. We ended the meeting with a timely mini plenary, “Self-Care for Essential Workers.”

While we cannot discount the blessings of 2020, I, like many of you, am relieved to have it behind me. So, what is on the horizon? As we march into 2021, the PEM section is looking forward to providing you with more educational content and additional ways to engage and network with colleagues. Please let us know how we can best serve you. Finally, I would like to close by introducing you to our new section liaison and administrator, Stephanie Wauson—welcome to the team Stephanie! read more

Breaking News: Handling Pediatric Orthopedic Trauma

Mark Griffiths, MD, FAAP, FACEP

I had the opportunity to sit down with Dr. Jill Flanagan, a pediatric orthopedist in Atlanta, to gather her expert opinion on how to handle common issues that present themselves while on shift in the ED. Dr. Flanagan completed her medical school and orthopedic residency at George Washington University School of Medicine, followed by training with the Children’s Orthopedics of Atlanta fellowship program.

Dr. Griffiths: A common complaint we have with many of our college members is the lack of pediatric orthopedic availability on-site combined with the closest pediatric specialist being quite a good distance away from the referring facility. What kinds of fractures can be splinted and addressed at a later time versus those which absolutely need to be transferred that day/night (besides ones that are open or grossly displaced)?

Dr. Flanagan: Firstly, calling the site to which a child might be transferred and discussing the case with the on-call orthopedist is a good first step. For reference though, fractures such as lateral condyle or forearm fractures can wait up to a couple of days, particularly as it will allow time for the swelling to go down.

Injuries that need more immediate attention include, but are not limited to, supracondylar, displaced growth plate, femur and tibia fractures.

Dr. Griffiths: Emergency physicians are quite familiar with the various splints that need to be applied but occasionally run across issues such as children developing ulcers, particularly in the lower extremity splints. How do we best prevent the ulcers?

Dr. Flanagan: I find most emergency departments are using prefabricated splints since it is easy to put on but the downside is that it doesn’t mold as well as plaster. Issues with ulcers in the lower extremity splints don’t occur because they are walking on it but because of the poor molding that is inherent with the prefabricated splints. While putting on the splint, one could put in additional padding using either Reston foam or 3 extra layers of padding around the heel. One pro-tip is to have them “float their heel” when they go home. By applying pillows under the leg and allowing the heel to hang free, it decreases the pressure.

Dr. Griffiths: What are some things that you wished referring hospitals would do differently prior to transfer of the patient? I know for me, when I take a transfer call I’m always cognizant of whether the patient has received adequate pain control in the referring department and ensuring there is a plan for pain control en route.

Dr. Flanagan: Good question, and I do have a few things that I hear consistently that could be improved.

  • Not sending a de-identified x-ray to the orthopedist (via secured text message or email). It’s so much easier to understand the situation and construct a plan when the orthopedist can see the image
  • For femur fractures—not getting a foley catheter. These patients end up retaining so much urine because they don’t want to use the urinal or bed pan because that causes so much pain
  • Antibiotics not being given within 3 hours for open fractures (especially forearms, which tend to be missed). This has been found to be more important than the time to the OR.
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    2019 EMage Contest First Place Winner: Helluva Uvula

    Evan Laveman, MD Emergency Medicine PGY3
    Kelly Kelley, MSN, RN, CPNP, CNS
    Christopher Redgate, MD, MS, PEM Fellow PGY6

    Pediatric Emergency Department, Department of Emergency Medicine, Harbor-UCLA

    16-year-old male with no past medical history presented to the Pediatric Emergency Department (PED) for 4 months of nasal congestion worsening over the past month. He immigrated from Honduras with his father 20 days ago and over this time noticed a decreased ability to breath through his nose. Most troubling, he started to develop foul smelling nasal discharge mainly through his left nare. His only medical contact had been at a U.S. clinic when he first arrived where he was prescribed a nasal spray and cetirizine with no relief. He felt moderate sinus pressure but denied weight loss, fevers, chills, headache or vision changes.

    On examination, his left nostril was obstructed by a mass covered in foul smelling pus that could not be cleared with sneezing. Once irrigated and cleaned, the mass appeared to be a pink, vascularized mucosal structure (Image 1). The right nare was patent and normal appearing.

    On further examination, the nasopharynx appeared full and the uvula was midline but anteriorly displaced by a similarly pink mass which appeared to descend into the hypopharynx (Image 2). The submandibular spaces, peritonsillar and lingual architecture appeared normal. There was no proptosis, his phonation was normal, and remaining cranial nerve examination was unremarkable.

     

    Pictures (Exam Findings)

    Image 1:

     

    Image 2:

    Image 3:

    CT (Pictures)

    Image 4:

    Image 5:

    Image 6:

    A CT revealed an enhancing mass (Images 4-6) that occupied the entire left nasal cavity and obliterated the turbinates. The mass also invaded through the lateral wall of the left maxillary sinus down to the hypopharynx and was penetrated through the mucosa of the nasopharynx, explaining the anterior displacement and appearance of the uvula seen on examination.

    Conclusion

    Juvenile nasopharyngeal angiofibromas (JNA) are rare, highly vascular and aggressive tumors that almost exclusively present in adolescent males1. Primary vascular supply in almost all tumors arise from the internal maxillary artery, and some patients may present primarily with recurrent and poorly controlled epistaxis2. Almost all arise primarily in nasopharynx, but case reports have discussed extranasal manifestations that present with asymmetric facial swelling3. These tumors lead to local destruction and invasion, eventually extending through the ethmoid plate. This can lead to cranial nerve deficits that can present with anosmia, decreased visual acuity and limited extraocular movements. Treatment is surgical, and often is preceded by IR embolization2.

     

    References

  • Mehan, R., Rupa, V., Lukka, V. K., Ahmed, M., Moses, V., & Shyam Kumar, N. K. (2016). Association between vascular supply, stage and tumour size of juvenile nasopharyngeal angiofibroma. European Archives of Oto-Rhino-Laryngology, 273(12), 4295–4303. https://doi.org/10.1007/s00405-016-4136-9
  • Mishra, A., & Verma, V. (2019). Implication of embolization in residual disease in lateral extension of juvenile nasopharyngeal angiofibroma. Journal of Oral Biology and Craniofacial Research, 9(1), 115–118. https://doi.org/10.1016/j.jobcr.2018.12.001
  • Mishra, A., Verma, V., & Mishra, S. C. (2017). Juvenile ‘Perinasal’ Angiofibroma. Indian Journal of Otolaryngology and Head & Neck Surgery, 69(1), 67–71. https://doi.org/10.1007/s12070-016-1050-9
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