POTD: Foreign Body of the Nose

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Foreign body of the Nose

•        Most common age range: 2-5 yo

•        Most common FB: beads, beans, peanuts, toy parts

•        Beware of: button batteries and two magnets, as always.

•        Can lead to septal perforation/necrosis of tissue.

•        Be suspicious of nasal FB when you see unilateral discharge, often malodorous

•        Complications: infection, aspiration, epistaxis

  

To remove:

•        Topical lidocaine or afrin?

  • Pro: improve tolerance of/cooperation with the procedure

  • Con: risks displacement of the FB

 

How to remove

1) Mechanical extraction: You need a cooperative child and good visualization.

2) Suction: must exercise extreme caution not to push further back and aspirated into the trachea

3) Positive Pressure: Parent’s kiss, bag mask, continuous pressure

  • Start by asking the child to blow their nose, occluding the unaffected nostril as they do this. Sometimes, this alone may expel the foreign body.

  • Parent’s Kiss: One of my preferred methods. Has a 50 % success rate.

Kissing parent: The technique is performed by a parent by placing their mouth over the child’s (giving a ‘big kiss’), while they occlude the unaffected nostril. The parent then exhales into the child’s mouth, generating positive pressure, similar to that of nose blowing. See picture below for demonstration.

Nothing working? You may need an ENT consult because the FB is so posterior that above methods are futile.

Now that it’s removed:

·       Don’t forget to inspect for trauma or retained FB

References:

•        PEM playbook foreign bodies: excellent peds podcast by Dr. T Horeczko - ‎2015

•        Wiki EM: Nose foreign body

Look at this retro parent’s kiss!

Look at this retro parent’s kiss!

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POTD: Foreign bodies, Ears!

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This is a two part series for POTD. Foreign bodies: Ears and Nose! Today, Ears!

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Quick Anatomy review to help locate that FB:

•        Anatomy

–       medial 2/3 is fixed in temporal bone –where many FBs are lodged and/or where trauma

•        Ask yourself: is it graspable or non-graspable?

–       Graspable: 64% success rate, 14% complication rate

–       Non-graspable: 45% success rate, 70% complication rate

•        What instrument/method should I use for what?

–       Alligator forceps: think something graspable like paper, foam

–       Suction tip: think something non graspable like a round object such as a bead

–       Irrigation: think something non graspable like a bead (note: do not irrigate organic material as will swell or break apart)

–       Glue: something non graspable like a bead or organic material that might swell or break if irrigated

 

Pearls on insect FB:

·       Kill it first. They will fight.

-        What to use? Lidocaine jelly, viscous lidocaine (2%), lidocaine solution, isopropyl alcohol, or mineral oil.

-        After they are dead, you can remove or can send to ENT for removal (most patients will want it out, can you blame them?)

o    An ENT friend of mine says to keep the insect in the ear and let them remove because we tend to cause trauma. Something to keep in mind.

 

What if I caused or the FB (like that insect fighting for their life) caused local trauma?

•        TM rupture?

–       Keep dry

•        When to use otic abx drops

–       Any trauma or dirty FB injury (think: that insect crawling around) or canal lacerations/abrasions.

–       What to give? Ofloxacin drops or the very expensive ciprodex.

•        ENT f/u

 

Pitfalls

•        Inspect after removal

–       Something else in there? Abrasions/trauma and need prophylactic antibiotic ear drops

•        If at first you don’t succeed, try again. But consider changing the technique of removal. Remember the law of diminishing returns.

 

References:

Pem playbook: excellent peds podcast by Dr.  T Horeczko - ‎2015

Wiki EM: Ear foreign body

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It's getting hot in here - Pediatric Fevers

So, it's winter. Kids get sick. But really, 8-10 times a year is normal, so they're sick all the time! And they present to the ED with FEVER!!!!

What do you think about and what do you do with FEVER!?!?!?

- Fever = 38 degrees Celsius or 100.4 Fahrenheit

- Subjective fever per parents? Believe and work up/treat appropriately based on clinical presentation

- Determine exact onset and calculate fever duration (if since last night, it is only 1 day since <24 hours)

- Ask T-max
Thorough exams must include throat, ears, skin, oropharynx!

If suspect infectious etiology, treat with antipyretics:

Acetaminophen: 15 mg/kg every 4 hours, PRN

Ibuprofen (6 months and older): 10 mg/kg every 6 hours, PRN

The "alternating" approach of treating every 3 hours (Acetaminophen at 9, Ibuprofen at 12, Acet. at 3, etc) can help keep the kiddos' fever under control and keep them happy, hydrated, and hopefully home!

What to do!?


0-28 days infant: 

Orders: CBC with differential, Blood Culture, BMP, UA with culture, LP with CSF gram stain/cell count/culture/possible viral culture. +/- HSV PCR. +/- stool culture if presenting with diarrhea. CXR

Pathogens: Group B Strep, E. Coli, Listeria. Consider HSV

Treatment: Ceftazidime or cefotaxime + Ampicillin (for Listeria). or Gentamycin + Ampicillin. +/- Acyclovir (< 21 days, seizures, rash, mom w/ lesions)

**No ceftriaxone: ceftriaxone displaced bilirubin and places patient at increased risk for Kernicterus 

Dispo: Admit

29-60 days Infant: 

Similar to above, but more experienced pediatric clinicians may use clinical judgement regarding LP. In general, most general EM physicians should practice more conservative management and pursue LP. 

*Philadelphia/Rochester/Boston criteria for infants vary, hence the debate.*

Orders: CBC with differential, Blood Culture, BMP, UA with culture, LP with CSF gram stain/cell count/culture/possible viral culture. +/- HSV PCR. +/- stool culture if presenting with diarrhea. +/- CXR if respiratory symptoms. 

Treatment: Ceftazidime or cefotaxime + Ampicillin or Ceftriaxone. Skin infection: +vancomycin

Dispo: often admit, but again, clinical judgement. If you diagnose a UTI in a well appearing, eating infant and labs are normal WBCs, no bandemia, normal CSF, consider 1 dose of ceftriaxone and 24 hour follow up (be mindful of patient's family's education, access to healthcare/the hospital, reliability, health literacy, etc.). Do what is best for the patient. See reference from CHOP for an example:  https://www.chop.edu/clinical-pathway/febrile-infant-emergent-evaluation-clinical-pathway. Again - do what is best for the patient and appropriate for your level of pediatric training/experience. 

Acute Otitis Media: 

Bacteria: Strep pneumo (~80%), H. flu (especially if unvaccinated), Moraxella

Treatment: high dose Amoxicillin 90 mg/kg per day divided into 2 doses (to overcome strep pneumo's penicillin binding protein and H. flu's beta lactamase). If resistant, Augmentin (dose based off the amoxicillin) 


Pneumonia: 

Most common pathogens: 

< 3 weeks: E. coli, Group B Strep, Listeria

> 3 weeks: Strep pneumonia



UTI: 

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RSV/Bronchiolitis: Usually < 2 years old. Supportive care, often HFNC. Babies < 6 months are high risk and give good return precautions if child is well enough to go home.


Influenza: keep in mind children < 5 are all high risk, but children < 2 are at greatest risk. 

Treat with oseltamivir, even if after 48 hours for high-risk patients (young, immunosuppressed, asthmatic, renal disease, DM, neuromuscular disease, pregnant, long term care facilities). 

Oseltamivir dosing is BID for 5 days: <1 year old: 3 mg/kg. >1 year old and 15 kg or less: 30 mg. 

15-23 kg: 45 mg.  23-40 kg: 60 mg. > 40 kg: 75 mg.


Group A Strep Throat: Under 3 years old, do not develop Rheumatic heart disease so often do not require antibiotic treatments

Treatment: Low dose Amoxicillin. 45 mg/kg divided into 2 doses. 


Pyogenic Joint Infection: Most common age group is < 3 years old. 

Pathogen: Staph aureus is the most common pathogen and often with preceding trauma or URI

Treatment: Need ortho consult and include MRSA antibiotic coverage

References:

https://www.chop.edu/clinical-pathway/febrile-infant-emergent-evaluation-clinical-pathway

Harriet Lane - the whole book is a reference gem, but looked up each topic

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Pediatric Nutrition

To supplement our new pediatric reference cards, I've included some things in this e-mail which were not covered.

Weight Gain

  • Proper weight gain is 25-30 grams/day for first 4-6 months.

  • After 4-6 months patients should double their birth weight.

  • Patients regain birth weight by 10-14 days.

Pediatric Fluid Resuscitation

  • Bolus: 20mL/kg

    • Remember, in sepsis can do 3x bolus = 60 mL/kg

  • Maintenance Fluids - The 4-2-1 rule

    • Add the following for each 10kg of body weight:

    • 4mL/kg

    • 2mL/kg

    • 1mL/kg

    • e.g. 24 kg child = (4mL*10mL/kg) + (2mL*10mL/kg) + (1mL*4mL/kg) = 64 mL/kg

Pediatric Dextrose/Hypoglycemia Resuscitation

  • The dextrose Rule of 50

    • Multiple your % dextrose solution supplied in ED by the ml/kg to give to patient to give and set equal to 50

    • In other words, divide 50 by the % dextrose solution you have available

    • For D10: 10X=50 i.e. give 5mL/kg of D10

    • For D25: 25X=50 i.e. give 2mL/kg of D25

    • For D50: 50X=50 i.e. give 1mL/kg of D50

Pediatric wet diaper output

  • Proper output is 1-2ml/kg/hr

  • Practically, patients should have 4-6 wet diapers per day.

    • Remember to base this off patient's "normal" as some parents do not change diapers as often.

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Intranasal Analgesia and Anxiolysis

Today we will be discussing IN anxiolysis and analgesia, especially useful in our pediatric population.  An appendix with a BAN administration outline is also attached. Indications

Perfect for kids coming in with acute trauma (laceration, need for x-rays, etc) or patients undergoing procedures such as I&D of an abscess.

May be used prior to obtaining x-rays for pain control in children not necessarily needing a line for reduction (or even in those needing a line as this may be a faster way to reduce pain, and may help provider in obtaining IV line).

 

Routine Medications – Analgesia/Anxiolysis Dose

  • Analgesia: Fentanyl (1-1.5mcg/kg), Ketamine (0.5mg/kg)

  • Anxiolysis: Midazolam (0.2mg/kg)

 

Other IN Medications: Midazolam, Precedex (dexmedotomidine), flumazenil, naloxone

 

Pearls of Administration

Have patients blow their nose first if possible.

Try to limit dose to 0.3mL per nostril (certainly no more than 1 mL per nostril), using concentrated solutions. 

Divide larger volumes over two nostrils.

May deliver in aliquots 10-15 minutes apart if larger.

Remember, it’s a good idea to put patients on a pulse ox prior to administration.

Account for “dead space” of atomizer (~1mL).  

APPENDIX

BAN Dosing

Remember, there is also the BAN (breath actuated nebulizer) for medication administration which is a an alternative to intranasal medications when tolerated.  Only use BAN in Breath Actuated Mode in ED.

Here is the dosing for BAN:

  • Fentanyl:

    • Adults: 4mcg/kg dose titrated q 10 min up to three doses

    • Pediatrics: 2-4 mcg/kg titrated q 10 min up to three doses

  • Morphine:

    • Adults: 10-20 mg titrate q 10-15 min up to three doses

    • Pediatrics: 0.2 mg/kg q15 min up to three doses

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