EMS Protocol of the Week - Pediatric Asthma/Wheezing

Last week, we went over the REMAC protocol for asthma, but in a cliffhanger not seen sinceAvengers: Infinity War, we were all left wondering what NYC EMS does with asthmatic/wheezing kids. Well worry not, faithful readers, because this week we’re taking a look at Protocol 554 – Pediatric Asthma/Wheezing!

There are a bunch of pediatric-specific protocols (remember that for the NYC REMAC, pediatric means up to 15 years of age), each with certain differences from its adult counterpart. Some differences are subtle, some not, so it’s worthwhile to at least have some awareness that these peds protocols exist in case the OLMC phone rings for a kid.

Protocol 554 is a good place to start with pediatric protocols since it’s not hugely different from 507, which we discussed last week. Albuterol and ipratropium are still being utilized as Standing Order, although a half dose of ipratropium is instructed for kids less than 6 years old. Further, while the adult protocol permits for continuous albuterol to be used, the pediatric protocol only allows for 3 doses as Standing Order. For children older than one year in severe distress, medics will also give epinephrine as Standing Order at a weight based dose (up to 0.3mg IM, the adult dose). After this point, OLMC may be utilized to request additional albuterol nebs and repeat doses of epi.

At this point, the only other significant difference in management is that the pediatric protocol does not include steroids or magnesium as adjuncts to treatment, either as SO or MCO, so just be aware that these kids will likely not have received any of those meds by the time they reach the ED (as opposed to adult patients).

That’s pretty much it for pediatric wheezers. Similar to the adult protocol, this one will generally leave most kids (and their parents) feeling much better by the time you see them, but just be aware of what may or may not have been done for them before immediately sending them out the door.

We’ll revisit other pediatric-specific protocols in the future, so be sure to keep an eye out! In the meantime, here’s your weekly plug forwww.nycremsco.org and the protocols binder by the OLMC phone.

David Eng, MD

Assistant Medical Director, Emergency Medical Services

Attending Physician, Department of Emergency Medicine

Maimonides Medical Center

POTD: Retropharyngeal Abscess

Retropharyngeal Abscess

What is it?

• Polymicrobial abscess in space between posterior pharyngeal wall and prevertebral fascia

• Adults: Usually due to direct extension of local infection (ex. ludwig's angina, pharyngitis, dental abscess etc.)

• Peds: Usually due to suppurative changes in local lymph nodes from an infection in the head or neck

• Can also be caused from trauma- falling with pencil in mouth

Presentation:

• Patients may prefer to lay down to prevent abscess from collapsing the airway. If your suspicion is high enough, don't sit these patients up!

• Patients will complain most commonly of: sore throat, fever, torticollis, dysphagia

• In late stages will develop airway involvement (looks for stritor, change in phonation, drooling, neck stiffness, tripoding, SOB)

Diagnosis:

• CT Neck with IV contrast

• On CT you will see loss of definition between the anatomic spaces in the neck, stranding in the subcutaneous tissues, tissue enhancement, and frank abscess formation, the location of the findings indicates whether it is a parapharyngeal or retropharyngeal space infection

• You can get a soft tissue neck x-ray, but if your suspicion is still high and the x-rays are equivocal, you should still get a CT

• MRI is useful for assessing the extent of soft tissue involvement and for delineating vascular complications

Management:

• Get Anesthesia/ ENT involved early if there is any degree of upper airway obstruction!

• These signs include: neck extension/head in sniffing position, stritor, change in phonation, drooling, neck stiffness, tripoding, SOB,  retractions

• Coordinate with Anesthesia/ ENT to secure an airway (Tracheostomy in the OR or fiberoptic intubation should be considered)

• If there is no airway compromise, consult ENT because many of these patients require I&D/ needle aspiration in the OR

• Retropharyngeal abscess <2.5cm without airway compromise can potentially receive a trial of empiric IV abx for 24-48 hours without drainage  

•  Antibiotics (Covering: GAS, Staph aureus, respiratory anaerobes, +/-MRSA)  options include: Ampicillin/Sulbactam 3g IV  or Clindamycin 600-900mg IV or Cefoxitin 2gm IV  

• Admit

Paraphimosis and Phimosis

What is it?

Paraphimosis: the penile foreskin becomes retracted around the coronal sulcus (= the circumference at the base of the glans penis), leading to vascular congestion and glans edema

Phimosis: the foreskin is retracted over the glans

This is only an emergency if it is causing acute urinary retentionKeep in mind most uncircumcised infants have normal phimosis

Why do we care?

 If left untreated, paraphimosis can lead to some awful complications, such as necrosis or gangrene of the glans penis which can then necessitate a partial amputation of the penis 

For phimosis causing urinary retention, can cause infections and renal failure

When to suspect it?

The main risk factor is lack of circumcision.

Crying infants (the S=Strangulation in ITCRIES for those who love mnemonics)

Adolescents may present later due to embarassment - can be caused by genital piercings or sexual intercourse 

Another risk factor is prolonged erotic dancing, ie wining - a gyrating motion that alongside others causes prolonged erection and friction on the penis (multiple case reports)

How do we manage it? 

Don't miss other injuries - look at their scrotum for a concomitant torsion or Fournier's 

Paraphimosis

Call urology urgently if you note signs of ischemia or the patient has had symptoms for >12 hours.

If there are no signs of ischemia, consider non-manipulative methods, which entail a combination of compression and osmotic agents as well as patience:

1. "Iced Glove" - place ice and water in a glove and invaginate the thumb portion to place the penis into

2. Mannitol or glucose soaked gauze - soak gauze in 20% mannitol or D50 and wrap it around the glans of the penis while applying gentle pressure; this can take 1-2 hours for full effect

Next, attempt manual reduction. Don't forget pain control!

Methods of analgesia: topical EMLA, dorsal penile nerve block, fentanyl, ketamine, procedural sedation (though certain studies have shown topical anesthesia may work best) 

Manual reduction: Have both thumbs on the glans while applying countertraction with the index fingers to the foreskin

If it works, make sure the patient can freely urinate , instruct patients to not retract the foreskin for 2 weeks, and arrange urology followup in 2-3 weeks. 

If it fails, URGENT urology consultation. There are other options in case of a failed manual reduction (injecting hyaluronidase, aspirating the glans, poking the foreskin) that are especially useful if no one is immediately available to assist you 

Phimosis

If causing acute urinary retention, call urology for likely dorsal slit procedure.

If patient is able to freely urinate, educate patient on how to properly clean their foreskin and show them how to retract the foreskin (3 months of this exercise has been shown to lead to resolution of phimosis in 76% of patients).

Topical steroids (triamcinolone for 4-6 weeks) also improve or completely resolve phimosis.

Sources

http://www.emdocs.net/em3am-paraphimosis-and-phimosis/

https://pedemmorsels.com/pediatric-paraphimosis/

https://www.aliem.com/trick-trade-management-paraphimosis/