Pediatrics

Question 1

Fluids in Pediatric Diabetic Ketoacidosis?

Answer 1

Children with diabetic ketoacidosis (DKA) may have brain injuries ranging from mild to severe. The debate over the contribution from intravenous fluids towards poor neurologic outcomes has been ongoing for decades.

PECARN’s large multicenter randomized, controlled trial examined the effects of the rate of administration and the sodium chloride content of intravenous fluids on neurologic outcomes in children with diabetic ketoacidosis may finally put the controversy to rest. There was no difference on significant neurologic outcomes based on the rate (fast vs slow) or concentration (0.9% vs 0.45%) of IV fluid administration.

Clinically apparent brain injury occurred in 12 of 1389 episodes (0.9%) of children in DKA.

Any change in the mental or neurological status of the patient should be concerning for life threatening edema and should be treated with mannitol 1g/kg IV bolus or hypertonic saline (3%) 5-10 mL/kg IV over 30 minutes.

BOTTOM LINE:

“Neither the rate of administration nor the sodium chloride content of intravenous fluids significantly influenced neurologic outcomes in children with diabetic ketoacidosis”

Question 2

ticks

Answer 2

The rainy East coast spring has increased tick populations in endemic areas such as Maryland resulting in more tick bites.

ED visits for known tick bites present acutely, often with parents bringing in the tick to be identified/tested.
Routine serologic testing and antibiotic prophylaxis is not recommended after every tick bite.

If an attached tick is engorged, identified as I. scapularis, and has been attached for >36 hours, then antibiotic prophylaxis for Lyme can be prescribed if started within 72 hours of tick removal in those patients > 8 years of age
Prophylaxis: Single dose of doxycycline 4 mg/kg or 200mg max

If early Lyme Disese is present in the form of the classic rash of Erythema migrans, then treatment is doxycycline, 4 mg/kg or 100mg max BID for patients > 8 years of age or amoxicillin 50 mg/kg per day divided TID with 500 mg max TID in those < 8 years of age for 14 days

Serologic testing is false negative in the first month of testing, and unnecessary in the ED for acute presentations.

Question 3

pediatric fever

Answer 3

• No matter what the school nurse says, only a temperature >/= 100.4 F or 38 C is a fever.
• Routine use of rectal and oral routes to measure temperature are not required to document a fever in children.
• Use of electronic thermometers in the axilla is acceptable even in children under 5 years
• Forehead chemical thermometers are unreliable.
• Reported parental perception of fever should be considered valid and taken seriously.
• Measure heart rate, respiratory rate, and capillary refill as part of the assessment of a child with fever.
• Heart rate typically increases by 10, and respiratory rate increases by 7 for each 1 C temperature increase.
• If the heart rate or capillary refill is abnormal in a child with fever, measure blood pressure.
• Do not use height of temperature to identify serious illness.
• Do not use duration of fever to predict serious illness.
• Tepid sponging/bathing, undressing, and over-wrapping are not recommended in fever.
• Do not give acetaminophen and ibuprofen simultaneously.