CEN Pediatric Emergencies: Ingestions, GI, Head Injury and Fractures

In depth

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Febrile neonates and young infants

Fever in an infant is a rectal temperature of 38.0 C (100.4 F) or more (Merck). The 2021 AAP guideline gives three algorithms (8 to 21, 22 to 28 and 29 to 60 days) but applies only to well-appearing term infants;. Merck treats ill appearance (abnormal cry, lethargy, rectal temperature over 38.5 C) differently: admit, obtain a white count, blood culture, catheterized urinalysis and culture (never a bag specimen) and CSF for cell count, culture and PCR if available, and start age-appropriate parenteral antibiotics until cultures are negative. Fever in an infant under 28 days means admission whatever the appearance.

Neonatal meningitis is caused mostly by group B streptococcus, E. coli and Listeria (Merck). Frequently only the findings typical of neonatal sepsis are present; lethargy, seizures, vomiting and irritability are more specific. Only about 20% have a bulging fontanelle or neck stiffness, so their absence reassures little. Merck lists ampicillin plus an aminoglycoside such as gentamicin, adding cefotaxime when gram-negative meningitis is suspected; hospital-acquired infection calls for vancomycin with an aminoglycoside, with or without a third-generation cephalosporin, or a carbapenem. Older patients and adult regimens are on CNS Infections.

Ceftriaxone, common in older infants (Merck names it for febrile infants 1 to 3 months), has neonatal contraindications in its label: hyperbilirubinemic neonates, because it displaces bilirubin from albumin and risks bilirubin encephalopathy; premature neonates up to a postmenstrual age of 41 weeks; and neonates 28 days or younger who need calcium-containing IV solutions, including parenteral nutrition, because of ceftriaxone-calcium precipitates. Where a neonate may receive it, IV doses run over 60 minutes. The nurse who sees ceftriaxone ordered for a jaundiced neonate questions the order and asks for an alternative such as cefotaxime or gentamicin; slowing the infusion does not fix a contraindication, and the other antibiotics are not held.

Ethanol and cannabis in young children

Young children who drink alcohol, often from mouthwash, hand sanitizer or cologne, are at real risk of hypoglycemia, because ethanol impairs hepatic glucose production and their glycogen stores run out quickly (Merck). A fingerstick glucose is one of the few useful tests. Blood levels peak about 30 to 90 minutes after ingestion on an empty stomach. IV hydration does not significantly speed ethanol clearance; disposition depends on the clinical response rather than a level. Merck gives no observation period; the page's inference is that a child still symptomatic after a dextrose bolus stays for repeat glucose checks until clinically sober. Fomepizole is for methanol and ethylene glycol (Toxicology: Antidotes), not ethanol.

Edibles carry more THC per serving than the plant, and a candy or gummy can deliver a large dose per kilogram. Merck says THC doses above 5 mg/kg in children under 5 have been associated with respiratory depression needing oxygen, that THC ingestion belongs in the differential of unexplained altered mental status in young children, and that most patients need only observation and supportive care; charcoal may be considered within 2 h when the benefit outweighs the risk of vomiting. In Kaczor 2021 (32 children with edible exposures, one center), those aged 0 to 9 had bradypnea in 83% vs 5% of teens, admission in 83% vs 5%, PICU care in 58% vs 5% and respiratory support (nasal cannula to BiPAP) in 33% vs 5%; lethargy, ataxia, tachycardia and vomiting were common, and one 4-year-old seized. IV fluids were the most common treatment (59%) and 31% needed none; the page's reading is continuous respiratory and SpO2 monitoring with airway equipment at hand.

Swallowed foreign bodies

Most ingestions happen in children, and coins are the object swallowed most often (Au and Goldman 2021). A coin that has reached the stomach in a well child is managed at home: normal diet, stools watched (Au and Goldman: parents might monitor stool for 2 weeks), return for pain, vomiting or blood. If the object is not seen to pass, films are repeated every 48 to 72 h and then weekly, and an object still in the stomach after 3 to 4 weeks is removed (Merck). Merck: objects over 6 cm long or 2.5 cm wide rarely pass the stomach; Au and Goldman: batteries, multiple magnets and long, angular or two-pointed objects must be removed.

A single magnet usually passes. Several magnets, or a magnet with another metal object, attract each other across loops of bowel; the trapped wall can necrose, perforate or form a fistula while the child still looks well, so they are removed, and gastric magnets within endoscopic reach come out endoscopically (Merck, Au and Goldman). ESGE is an adult guideline, applied to children here: sharp-pointed objects, magnets, batteries and large or long objects in the stomach are urgent (within 24 h); complete esophageal obstruction and sharp-pointed objects or batteries in the esophagus are emergent (preferably within 2 h, at the latest 6 h); medium blunt gastric objects can wait up to 72 h. Esophageal button batteries, with their 2-hour burn clock, are covered on CEN: HEENT and EMT by Complaint.

Sharp objects in the stomach are retrieved because of perforation risk, and toothpicks and fish bones can stay in the gut for years, ending in a granuloma or abscess (Merck). Food impaction is the commonest esophageal problem, and older adults may be unable to give a history, so imaging may be needed (Merck). Fish and some chicken bones, wood, plastic, glass and thin metal are hard to see on plain films, so a normal film does not close the question; CT is used when suspicion remains or perforation is possible (Merck, ESGE). Barium swallow is avoided: it can be aspirated, leaks through a perforation and spoils the endoscopic view.

Intussusception, malrotation and Hirschsprung enterocolitis

Intussusception usually affects children 6 months to 3 years old, 70% of them under 2 (Merck). Colicky pain, vomiting and later currant-jelly stool is the textbook course, but about 15% have no pain phase and simply look lethargic, and the diagnosis is missed until blood or a mass appears. Do not wait for bloody stool. Ultrasound is the preferred first test (target sign). An air enema reduces most ileocolic cases (over 80%), followed by overnight observation; recurrence after nonsurgical reduction is about 13% or less. A failed reduction or perforation means surgery, and a child with peritonitis gets fluid resuscitation, broad-spectrum antibiotics, NG suction and surgery rather than an enema.

About 40% of malrotation presents in the first month of life and over 80% by age 5 (Merck). Bilious emesis in an infant is an emergency: a volvulus around the narrow mesentery strangles the superior mesenteric vessels and can infarct the midgut, leaving short bowel syndrome or death. Merck advises immediate plain films (double bubble or scant distal gas suggest obstruction), with the upper GI series the generally preferred study (ultrasound whirlpool sign in experienced hands); the page reads this as: a normal plain film does not end the evaluation. Treatment of volvulus is emergency surgery (Ladd procedure: detorsion, division of bands, widening the mesentery, appendectomy).

Most neonates pass meconium within 24 h; most with Hirschsprung disease have not passed it by 48 h (Merck). Up to 20% of term infants with the disease develop Hirschsprung-associated enterocolitis, mostly before surgery but also in the first year after: fever (temperature instability in neonates), distension, explosive or bloody diarrhea, then obstipation, with sepsis and shock that can follow quickly. Treatment is bowel rest, fluid resuscitation, NG and rectal tube decompression and broad-spectrum antibiotics covering anaerobes (for example metronidazole with ampicillin and gentamicin, or piperacillin-tazobactam); some experts irrigate carefully in infants who are not critically ill. Barium enema is not done while enterocolitis is suspected; the definitive diagnosis of Hirschsprung disease is rectal biopsy.

Minor head injury and return to sport

PECARN (Kuppermann 2009, 42,412 children) derived and validated rules for children with GCS 14 or 15 after head trauma. For age 2 and older, a child with normal mental status, no loss of consciousness, no vomiting, a non-severe mechanism, no signs of basilar skull fracture and no severe headache is at very low risk: in validation the negative predictive value was 3798 of 3800 (99.95%) and sensitivity 61 of 63 (96.8%), and CT can routinely be avoided. GCS 14, other altered mental status or signs of basilar skull fracture put a child in the high-risk group that gets CT; the remaining findings leave observation or CT to the clinician after discussion with parents (Cho 2022). The under-2 rule is on Pediatric Emergencies.

CDC danger signs after a head injury: seizures, trouble recognizing people or places, repeated vomiting, unusual behavior or growing confusion, loss of consciousness or increasing drowsiness, slurred speech, weakness or numbness, a worsening headache, unequal pupils or double vision; in infants and toddlers also inconsolable crying and refusing to nurse or eat. An athlete with a suspected concussion leaves play right away and does not return the same day. CDC HEADS UP return: back to regular activities with provider approval, light aerobic activity, moderate activity, heavy non-contact activity, full-contact practice, then competition; each step usually takes at least 24 h, and if symptoms return the athlete stops, contacts the provider and restarts at the previous step after rest. Return usually takes a week or more.

Stridor that is not croup; sickle cell fever

Viral croup affects mainly children 6 months to 3 years old, and recurrent afebrile episodes in that age range are often called spasmodic croup (Merck). AAFP (Smith 2018) calls onset before 6 months atypical and reserves laryngoscopy for atypical presentations; its differential lists hemangioma (under 6 months, stridor worse with crying) and large airway lesions such as subglottic stenosis, laryngomalacia and tracheomalacia (recurrent barking cough and stridor), both diagnosed by airway endoscopy. A 4-month-old with recurrent episodes and noisy breathing needs that referral rather than a spasmodic croup label. Typical croup care is on Pediatric Emergencies (AAFP: dexamethasone 0.6 mg/kg once is the usual dose; observe at least 2 h after racemic epinephrine).

Children with sickle cell disease lose splenic function and are open to sepsis from encapsulated bacteria. CDC tells families to go to the ED for 38.5 C (101.3 F) or more, since fever may be the only sign of infection. The national quality indicator quoted by McKinney 2020 calls for parenteral broad-spectrum antibiotics within 60 minutes of triage for fever of 38.5 C or more; adherence to penicillin prophylaxis and pneumococcal vaccination is often incomplete. A 60-minute antibiotic target cannot be met from the waiting room, so the page places a febrile sickle cell patient at ESI level 2 (the page's inference; the ESI v5 handbook was not opened and Triage: ESI does not list this case) (the page's reading of the high-risk situation logic, not an ESI v5 quote). Pain crises and acute chest syndrome are on Medical, Neuro, Endocrine and Blood.

SCFE, growth-plate injuries and toddler fractures

Slipped capital femoral epiphysis appears after puberty starts, usually at 12 to 16 in boys and 10 to 14 in girls, and most patients are above the 95th percentile for weight (OrthoInfo). In a stable slip the child can still walk and has activity-related pain in the groin, hip, thigh or knee; limited, painful internal rotation of the hip is the clue, so a child with knee pain and a normal knee film gets a hip exam. Two views of the pelvis and hips confirm it. Once SCFE is confirmed the child bears no weight on the hip, and surgery is usually within 24 to 48 h. The other hip slips in some children, usually within 18 months.

Growth plates are the last part of a child's bone to harden and are particularly vulnerable (OrthoInfo). Salter-Harris (Merck SALTR): I straight across the physis, II above (most common), III lower into the epiphysis, IV through all three, V rammed (crush). Types I and V can look normal on films, so tenderness over the physis after a fall is treated as a fracture: splint or cast and re-examination in several days. Types III and IV often need open reduction and internal fixation, and the risk of growth disturbance rises from I to V. Alignment can be lost 1 to 2 weeks after casting, and follow-up continues for at least a year (OrthoInfo).

A toddler's fracture is an undisplaced spiral or oblique fracture of the distal tibia, usually with an intact fibula, in a walking child under 3, from a low-energy twist or fall (Patel 2018). The child limps or refuses to bear weight; films may be normal at first, with periosteal new bone 1 to 2 weeks later. Treatment is a long-leg cast for 2 to 3 weeks and then a short-leg cast for 2 to 3 weeks. Children under 24 months with possible abuse get a skeletal survey (Merck), but the CHOP ED pathway exempts a distal spiral tibia or fibula fracture after a fall while walking or running at 12 to 23 months when there are no clinical concerns. Concerns that change this: confessed abuse, injury during domestic violence, a delay of more than 24 h for a child in distress, other injuries such as bruises or burns, no history that explains the fracture, or a child not yet walking (any fracture under 12 months, with narrow exceptions). Reporting turns on reasonable suspicion, not on fracture shape (Merck; ED Forensics and Abuse).

Exam pearls

• Green vomit in a neonate is volvulus until proven otherwise.
• A jaundiced neonate does not get ceftriaxone; ampicillin plus gentamicin or cefotaxime.
• One normal glucose does not clear a child who drank ethanol.
• Several magnets come out, even in a well child; one coin goes home.
• A normal film does not exclude a wooden toothpick.
• Intussusception can present as lethargy alone.
• Explosive stools after late meconium mean enterocolitis, not relief.
• Knee pain in a heavy adolescent: examine the hip.
• A spiral tibia fracture in a walking toddler with a matching story is usually accidental.