Rosen & Barkin's 5-Minute Emergency Medicine Consult (514 page)

FOLLOW-UP

• Heart failure
  
• Endocarditis
  
• Pulmonary hypertension
  

• Asymptomatic
  
• Prophylactic antibiotics
  
• Close follow-up with plans for early surgical closure
  

A pediatric cardiologist/neonatologist should be involved in all patients who have any evidence of heart failure, particularly if pharmacologic management is being considered.

• CHF may cause decrease in glomerular filtration rate and urinary output.
  
• Indomethacin may cause GI bleeding.
  

• Dorfman AT, Marino BS, Wernovsky G, et al. Critical heart disease in the neonate: Presentation and outcome at a tertiary care center.
  Pediatr Crit Care Med
  . 2008;9:193–202.
  
• Laughon M, Bose C, Benitz, WE. Patent ductus arteriosus management: What are the next steps.
  J Pediatr.
  2010;157(3):355–357.
  
• Moore P, Brook MM. Patent ductus arteriosus and aortopulmonary window. In: Allen HD, Driscoll DJ, Shaddy RE, et al., eds.
  Moss and Adams’ Heart Disease in Infants, Children, and Adolescents: Including the Fetus and Young Adult
  . 8th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2013:722–745.
  
• Nemerofsky SL, Parravicini E, Bateman D, et al. The ductus arteriosus rarely requires treatment in infants >1000 grams.
  Am J Perinatol
  2008;25:661–666.
  
• Webb GD, Smallhorn JF, Therrien, J, et al. Chapter 65: Congenital heart disease. In: Bonow RO, Mann DL, Zipes DP, et al., eds.
  Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine
  . 9th ed. Philadelphia, PA: Elsevier Saunders; 2012:1411–1468.
  

See Also (Topic, Algorithm, Electronic Media Element)

• http://www.nhlbi.nih.gov/health/health-topics/topics/pda/
  
• http://www.nlm.nih.gov/medlineplus/ency/article/001560.htm
  
• http://www.heart.org/HEARTORG/Conditions/CongenitalHeartDefects/AboutCongenitalHeartDefects/Patent-Ductus-Arteriosis-PDA_UCM_307032_Article.jsp
  

CODES

747.0 Patent ductus arteriosus

BASICS

• Pathophysiology and anatomy of adolescents and young adults are similar.
  
• 80% of pediatric trauma is blunt; 80% of multisystem trauma includes head injury.
  
• Trauma is the leading cause of death and disability in children >1 yr in US and Europe.
  
• Most victims of child abuse are <3 yr. 1/3 of these patients are <6 mo.
  

• Most cases of pediatric trauma are single-system, minor, blunt injuries.
  
• Common mechanisms of injury include motor vehicle collisions and bicycle accidents, struck by a vehicle as a pedestrian, and fall from height.
  
• Penetrating injuries are rare in younger children.
  
• Risk factors include inadequate supervision, developmental inadequacy of child to perform task, inadequate attention to task, risk taking, drugs, and alcohol.
  

DIAGNOSIS

• History is often straightforward and provided by the child, parents, witnesses, or paramedics. If inconsistent with injury, consider child abuse.
  
• Mechanism(s) of injury relatively poor predictor of injury severity, but may suggest type of injury.
  
• Variables that increase the likelihood of serious injuries include handlebar injuries, significant passenger space intrusion, and failure to use proper restraint during a motor vehicle collision or helmet when riding a bike or skateboard.
  
• AMPLE history includes
  a
  llergies,
  m
  edications,
  p
  ast medical history, time of
  l
  ast meal, and
  e
  vents leading up to injury.
  

• Primary survey:
  
  • For all children who have sustained a major trauma, a traditional stepwise ABCDE evaluation based on assessing the
    a
    irway,
    b
    reathing,
    c
    irculation,
    d
    isability, and
    e
    xposure is appropriate.
    
• Secondary survey:
  
  • General:
    
    • Mass-to-surface ratio may impact insensible water loss and increase the risk of hypothermia.
      
    • Compensatory mechanisms may delay signs of hypovolemia. Few findings may be present until loss of 25–30% of blood volume, at which time decompensation abruptly occurs.
      
    • Smaller total blood volume (80 mL/kg)
      
  • Head:
    
    • Note bulging fontanel, scalp hematomas, midface instability, auricular and septal hematomas, lacerations, functional or cosmetic deformities to the face, and pupillary abnormalities.
      
    • Open sutures/fontanelles or multiple skull fractures may delay the onset of other signs and symptoms of increased intracranial pressure.
      
    • Large head/occiput causes cervical spine flexion when patient is supine on adult backboard.
      
  • Eye/ears, nose, and throat exam:
    
    • Look for evidence of blood, trauma, hemotympanum, hyphema, and CSF fluid.
      
    • Large tongue and tonsillar hypertrophy may obstruct the airway.
      
  • Neck:
    
    • Tracheal deviation and posterior neck step-offs are exceedingly unusual in children.
      
    • Shorter trachea increases risk of right mainstem intubation.
      
    • Cricoid cartilage is narrowest portion of airway in children <8 yr.
      
    • Children with altered mental status cannot have their cervical spine precautions cleared in the ED. These children should remain in a cervical collar (and be taken off the spinal board) while in the ED.
      
    • Pseudosubluxation (anterior displacement of C-2 on C-3) occurs in 20% of patients.
      
    • The term spinal cord injury without radiologic abnormality (SCIWORA) is controversial in the MRI era.
      
  • Chest:
    
    • Note the overall work of breathing, grunting, asymmetric breath sounds, posterior abrasions, chest wall deformities, and crepitus.
      
    • Flexible and compliant chest walls make pulmonary contusions more likely than rib fractures in young children. Rib fractures may be a sign of abuse.
      
    • Diaphragmatic breathing
      
  • Abdomen:
    
    • Bruising, abrasions, and tenderness
      
    • Distention is usually caused by gastric air.
      
    • Liver and spleen relatively large
      
    • Rib cage covers less of abdomen.
      
    • Bladder is intra-abdominal in children <2 yr.
      
  • Extremities:
    
    • Palpation and evaluation of joint stability and tenderness
      
    • Assess pulses and compartments.
      
    • Salter–Harris classification of fractures
      
    • Unique injuries: Greenstick and buckle fractures
      
  • Neurologic exam:
    
    • Age-appropriate mental status assessment
      
    • Assess movement of the extremities.
      
  • Skin:
    
    • Assess for prolonged capillary refill and pallor.
      
    • Bruising of the ears, dorsa of the feet, or genitalia may suggest nonaccidental trauma.
      
  • Patterns of injury:
    
    • Car vs. pedestrian: Waddell triad (femur, torso, and head injuries)—uncommon
      
    • Bicycle handlebar injuries may impale child: Pancreatic or small bowel injury.
      
    • Lap belt syndrome: Abdominal ecchymoses and intestinal injury with or without lumbar spine fracture (chance fracture)
      
    • Minor trauma history with major injury: Consider child abuse
      

• History and age-appropriate physical exam are the only essential components to a workup for all children who present for an evaluation following trauma.
  
• Obtaining standard radiographic and lab “trauma panels” is not evidence based in children.
  

• Lab tests should generally be individualized, reflecting the patient’s clinical presentation.
  
• A normal initial hemoglobin and hematocrit do not rule out a significant hemorrhage but will provide a baseline value for later comparison; tachycardia may be only sign of fluid/blood loss early in presentation, although it is nonspecific for blood loss.
  
• Initial electrolyte measurement is unnecessary.
  
• Routine amylase and lipase are not recommended because of the low incidence of pancreatic injuries; false-positive tests are common.
  
• Elevated LFTs should not be used as the sole determinant in deciding which children should undergo CT of the abdomen. Patients with AST >200 IU/L or ALT >125 IU/L who have sustained abdominal trauma should be considered for CT if hemodynamically stable. Physical exam should guide imaging decision.
  
• Gross hematuria (>50 RBC/HPF) is concerning for urinary tract injuries, but microscopic hematuria is not.
  
• Blood bank specimen for typing in appropriate patients
  
• A pregnancy test is indicated for teenage girls.
  
• Diagnostic peritoneal lavage is rarely indicated with availability of imaging modalities.