Episode 10 (iTunes or listen here)

The Free Open Access Medical education (FOAM)

We review Dr. Natalie May’s brilliant post on the St. Emlyn’s blog, “When Sick Means Sick: Emesemantics and Vomiting in Kids”  in which she dissects emesis descriptors such as bilious, projectile, and coffee-ground.

The Pearls:

• Ask for color descriptors or look at the emesis yourself rather rely on typical descriptors of emesis.
• Bilious vomiting, medical speaking, means emesis that appears like cooked, green spinach – not the yellow color that parents often mean. While sometimes normal in older children with gastroenteritis, in neonates or anyone sick appearing, this represents a surgical emergency such as volvulus, malrotation, necrotizing enterocolitis etc.

• Projectile vomiting – Most vomit is projected at least a short distance, so parents may say even reflux is projectile.  Observe a test feed to gauge whether a baby is vomiting or has true projectile vomiting which may represent idiopathic hypertrophic pyloric stenosis.
• Coffee ground emesis – this is a blackish-brown gritty emesis but parents may mean any brown-ish vomit.  This is typically indicative of upper GI bleed, which is pretty rare in pediatric patients.

The Bread and Butter

We summarize some key topics from the following readings, Tintinalli (7e) Chapters 111,124; Rosen’s 8(e) Chapter 172 but, the point isn’t to just take our word for it.  Go enrich your fundamental understanding yourself!

Neonatal Jaundice

Physiologic Jaundice – Jaundice in healthy, full-term newborns typically develops during the 2nd – 3rd day of life and resolves by the 5th or 6th day.  This occurs a little later in Asian and premature infants.

• Mean peak total serum bilirubin is 6 mg/dL
• Use the nomogram in infants >35 weeks gestational age to determine need for phototherapy

Non-physiologic Jaundice – bad.

• Jaundice in the first 24 hours
• Bilirubin rising faster than 5 mg/dL in 24 hours •Clinical jaundice >1 week
• Direct bilirubin >2 mg/dL
• In healthy term infants total serum bilirubin concentration >15 mg/dL (so remember: average of 6 but more than 15 is bad. But check out the nomogram in non-preemies).

Indirect Neonatal Jaundice – 3 main causes, listed below. Treatment is with phototherapy and mitigation of underlying causes.

• Increased lysis – this can be due to lysis of red blood cells or sequestration of blood – ABO incompatibility, splenic sequestration, spherocytosis.
• Decreased hepatic uptake/decreased conjugation – Immature transfer enzymes (babies grow out of this), breastmilk jaundice (lack certain enzymes, idiopathic hypertrophic pyloric stenosis (unclear why), as well as Gilberts, Crigler Najjar Syndrome
• Increased enterohepatic uptake (i.e. too much reclaimed from the gut) – obstruction or breastfeeding jaundice (dehydrated babies who are breast feeding).

Direct Bilirubinemia

• Etiology – biliary tree obstruction or biliary atresia, enzyme deficiencies (cystic fibrosis, alpha-1 antitrypsin deficiency, glycogen storage diseases)
• Conjugated bilirubin is non-toxic so treat the underlying cause

Emergency Department Diagnostics:

• Total and Fractionated Bilirubin,  Blood Type with Rh factor, Coomb’s test, blood count, Reticulocyte count, consider sepsis work-up .

More FOAM

• EMPEM – Neonatal Jaundice

Intussusception

Presentation: Abdominal pain, vomiting, bloody or guaiac positive stool.  The classic triad is not useful and present in 15-20%.  While intussusception is most common at approximately 1 year of age and, moreover 2 months -6 years, it can present at any time, including the elderly.

Etiology:  The bowel telescopes on itself and

Diagnosis:  Clinical, ultrasound (target sign), or diagnostic and therapeutic air contrast enema. It’s also reasonable to get plain films, if desired.

Treatment:  Air contrast enema in radiology results in approximately 60% success so most recommend a surgery consult in the event there’s a complication or failure in radiology.  Also, give these patients 20cc/kg fluid bolus and treat their pain.

More FOAM:

• Peds EM Morsels – Intussusception
• PEM Blog – Abdominal X-ray in Intussusception, Ultrasound in Intussusception, The Basics, Treatment

Generously donated Rosh Review questions (scroll for answers)

Question 1. A 10-month-old previously healthy boy presents with 1 day of bilious vomiting and fever. The patient is ill-appearing. Physical examination reveals a distended and diffusely tender abdomen with guarding and rebound. [polldaddy poll=8224476]

Question 2. A 2-year-old ex-33 week premature girl presents with vomiting, diarrhea and poor feeding. The patient has episodes of fussiness and inconsolable crying followed by periods of lethargy and sleeping. During periods of fussiness, the patient draws her legs up to her chest. [polldaddy poll=8225869]

Also, check out “Ketamine, The Album” – A musical written by and for emergency physicians as a tribute to ketamine

 

Answers.

1.Correct Answer ( A ) This patient presents with signs and symptoms concerning for an obstruction secondary to a volvulus and requires emergent surgical evaluation. Malrotation is a relatively common occurrence (1 in 500 live births) and about 75% of patients with malrotation will develop volvulus. During embryonic development, rotation of the gut arrests. This allows for the small bowel to twist around the superior mesenteric artery causing an acute obstruction. Patients will present with sudden onset of abdominal distension and bilious emesis. These infants will be ill-appearing and possibly toxic on presentation. Although a number of diagnostic modalities can be employed for definitive diagnosis, the priority in an ill-appearing infant with bilious emesis is emergent surgical consultation. All other interventions risk delaying definitive management. While waiting for the surgical consultation, the patient should have an IV placed, fluid resuscitation begun and a nasogastric tube placed for decompression of the stomach. Additionally, broad spectrum antibiotics should be administered. After consultation, an upper GI series may be obtained for definitive diagnosis.

Stool cultures (B) are useful when there is a suspicion for infectious process such as a parasitic or bacterial infection. Laboratory studies (C) will provide limited data and should not delay definitive management by a surgeon. The patient should receive intravenous hydration, not oral rehydration (D) as there is a high likelihood that this patient will be taken to the operating room. As such, the patient should be kept NPO.

2. D.  This patient presents with symptoms concerning for intussusception and should have an emergent ultrasound performed to make the diagnosis. Intussusception is defined as the telescoping of one segment of the intestine into another. It is the most common cause of obstruction in children younger than 2 years of age. The classic triadof intussusception is abdominal pain, vomiting and bloody stools but all three features are only present in about 33% of patients. Bowel movements may be loose with mucous and blood and appear like “currant jelly.” Often patients will have cycles of severe abdominal pain lasting 10 to 15 minutes during which they are inconsolable. These episodes are followed by periods of painlessness during which the child may be lethargic. Palpation of the abdomen may reveal a sausage-like mass in the right upper quadrant representing the actual intussusception. The lead point for the telescoping may be due to Henoch-Schonlein purpura vasculitis, Meckel’s divericulum, lymphoma or polyps in children over 5 years of age. In younger children, enlarge Peyer’s patches may be the culprit. These occur after viral infections. Ultrasound of the abdomen is the best initial modality for identifying the intussusception. It may reveal the classic findings of a target sign or “pseudokidney” sign. Sensitivity and specificity of ultrasound approach 100%.  Abdominal X-ray (A) may show intussusception but may be negative in up to 20% of patients. CT(B) and MRI (C) of the abdomen and pelvis  are also unreliable in the diagnosis.