Preterm Neonatal Resuscitation

Written by: Aaron Wibberley, MD (NUEM ‘22) Edited by: Vidya Eswaran, MD '20 Expert Commentary by: Spenser Lang, MD

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Expert Commentary

Thanks to Dr. Wibberley and Dr. Eswaran for providing this infographic on a tough topic – neonatal resuscitations.

Usually, deliveries in the emergency department cause a dichotomy of emotions – initial anxiety, then relief and happiness. Most of our deliveries tend to be quick, precipitous, with hopefully just enough warning for us to grab gloves and remember where the baby warmer is. Unfortunately, when babies decide to struggle with their first few minutes of life, this becomes a lot more stressful for everyone.

Fair warning – though I am an emergency medicine physician, and prepared to deal with emergent situations of any age, I think there are very few of us who feel as comfortable with neonatal resuscitations as we do with critically ill trauma or cardiac arrest patients. Especially if your department sees very little pediatrics, it is completely normal to feel anxiety when imagining resuscitating a neonate, and even more so a pre-term baby. This is OK! In fact, this should motivate you to get familiar with NRP, and provides a perfect opportunity for spaced repetition throughout your career to enhance recall.

Here are my broad strokes steps for a fresh neonate requiring resuscitation.

#1: Know your resources! The first step in managing a neonatal resuscitation occurs far before the patient shows up in your department. Where is your baby warmer? Where are your teeny-tiny BVM’s? What’s the smallest ETT and intubating blade you stock, and where?  I promise you, the hardest part of intubating this baby won’t be the actual mechanics of placing an ETT – it will be in the preparation and supply gathering. Don’t rely on your nurses to know everything when seconds count – know where this stuff is yourself.

#2: Call for help, early and often. Many emergency departments have some type of OB/imminent delivery response – hopefully this brings in a pediatrician well trained in neonatal resuscitation as well. Hopefully, this also brings a nurse who is used to placing IV’s in these itty bitty babies. If this doesn’t describe your hospital, call to start the transfer process, and move on to #3…

#3: Dry and stim. Nearly all babies respond to drying and stimulation. Please don’t start bagging a poor newborn before drying it off and giving it a good rub for 30-60 seconds (unless it’s extremely pre-term – try to avoid rubbing all the skin off of a 25-weeker, this is bad form.) At the same time, keep in mind that these babies will need some form of external thermoregulation so make sure the warmer is actually functioning.

#4: When in doubt, fix the breathing. As is obvious when scanning through NRP guidelines, 95% of managing a sick newborn lies in assisting the respirations. Poor tone? Fix the breathing. Initial HR below 100? Try to fix the breathing. Poor color? You get it. Don’t be afraid to escalate from blow by, to PEEP, to BVM. If the baby has little to no respiratory effort, a couple initial breaths via BVM can quickly improve the situation. But please, when you’re bagging a tiny neonate, use small breaths – this is not the typical 120 kg patient we are used to.

#5: In the short term, an IO is your friend. A UVC is golden, but not really possible in an active resuscitation. The good news is that most babies don’t need IV access in the short term – for my  reasoning, see #3 and #4. The literature suggests that placing the neonatal IO in the proximal tibia, distal tibia, or distal femur can be safe and effective.

#6: This is the time to debrief. Whether a happy or a tragic ending, this is a rare and emotional event in the emergency department. Debrief with your team. Talk to whoever you talk to about this stuff – spouse, friend, coworker. We are champions of compartmentalization in the emergency department out of necessity, but don’t bear the entirety of these encounters on yourself – lean on those around you.

Spenser Lang, MD

Assistant Professor

Department of Emergency Medicine

University of Cincinnati

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How To Cite This Post:

[Peer-Reviewed, Web Publication] Wibberly, A. Eswaran, V. (2020, Nov 9). Preterm Neonatal Resuscitation. [NUEM Blog. Expert Commentary by Lang, S]. Retrieved from http://www.nuemblog.com/preterm-neonatal-resuscitation

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Pediatric Ankle Injuries

Written by: Nikita Patel, MD (NUEM PGY-2) Edited by: Paul Trinquero, MD (NUEM ‘19) Expert commentary by: Kristen Loftus, MD, MEd

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Expert Commentary

This is a succinct, high-yield review of pediatric ankle injury management. I appreciate the focus on radiograph-negative injuries, as only a minority will have a fracture identified on radiographs (~12%).

 You highlight a key point about the use of the Ottawa Ankle Rules (OAR). A few things I would emphasize/add:

• You most definitely do not need an x-ray on every pediatric patient with an ankle injury (though x-rays are obtained ~85-95% of the time).

• The OAR have indeed been well-validated in children. In clinical practice, the problem you run into with the pediatric population is that: 1) kids commonly refuse to bear weight even with mild ankle injuries and 2) in pediatric patients (as opposed to adults), isolated distal fibular tenderness typically suggests a low risk ankle injury where x-rays won’t change your management.

• The Low Risk Ankle Rule (LRAR) addresses these 2 key issues of using the OAR in kids, and it may be worth considering adopting the use of this clinical decision rule for pediatric ankle injuries. It was initially validated in children and is associated with a larger decrease in unnecessary radiographs compared to the OAR. [Boutis K, Komar L, Jaramillo D, et al. Sensitivity of a clinical examination to predict need for radiography in children with ankle injuries: a prospective study. Lancet. 2001;358:2118-21.]

No discussion on pediatric orthopedic injuries would be complete without a review of the Salter-Harris classification. There is a lot of practice pattern variation in the management of patients with negative radiographs but growth plate tenderness on exam (i.e. the potential Salter-Harris I fracture). The Boutis et al. group has done some great work in this area, and you highlight several key studies in your excellent review of the literature. I personally feel well-supported by this emerging evidence, and my practice pattern is to place patients in a removable ankle lacer (if able to bear weight) or a pneumatic walking boot (if unable to bear weight), with crutches as needed, and outpatient follow-up with their pediatrician versus Sports Medicine, rather than Orthopedics.

Kirsten V. Loftus, MD MEd

Division of Pediatric Emergency Medicine

Ann and Robert H. Lurie Children’s Hospital of Chicago

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How to Cite This Post

[Peer-Reviewed, Web Publication] Patel N, Trinquero P. (2019, Oct 21). Pediatric Ankle Injuries. [NUEM Blog. Expert Commentary by Loftus K]. Retrieved from http://www.nuemblog.com/blog/peds-ankle.

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Ultrasound in Pediatric Distal Forearm Fractures

Written by: Jason Chodakowski, MD (NUEM PGY-3) Edited by: Logan Weygandt, MD (NUEM ‘17) Expert commentary by: Rachel Haney, MD (NUEM ‘17)

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Why use Ultrasound?

Distal forearm fractures are common fractures in the pediatric population. Although plain radiographs of the forearm are still considered the gold standard for definitive diagnosis, there is growing interest in using ultrasound for diagnosis because it provides zero radiation exposure, it can be used to guide local pain control, and it can confirm reduction success at the bedside. Ultrasound is easy to teach and provides value under circumstances when plain radiography might be unavailable (pre-hospital environment, disaster areas, or in developing countries).

A recent meta-analysis of 12 studies, which included 951 children 18 and younger, found that physician performed bedside ultrasound detected distal forearm fractures with a pooled sensitivity of 98% and a specificity of 96% when compared with the gold standard plain radiographs.[1] The pain associated with ultrasound use was also significantly less.[2]

How do I use Ultrasound?

To evaluate musculoskeletal pathology use the high-frequency linear array transducer employing the six-view ultrasound technique as shown below. You may detect a fracture as an apparent discontinuity or irregularity (divots, step-offs, distortion) of the hyperechoic and continuous bony cortex. Disruptions as small as 1mm can be detected.

Six-view technique (Herren et. al. 2015)

Normal Cortex (Crosby et. al. 2014)

Distal radius fracture (emergencyultrasoundteaching.com)

Distal radius fracture (acep.org)

Pitfalls

In children the evaluation of bones is complicated by the open physes, which may be mistaken for fractures. The difference is that physes will appear as smooth, downward-sloping curves unlike fractures, which will have abrupt step-offs.

Normal open tibial physis (Crosby et. al. 2014)

What else is Ultrasound Good For?

• Confirming reductions

  Ultrasound is also utilized by emergency physicians to determine successful realignment of pediatric distal forearm fractures after closed reduction.[4]

Fracture reduction (Socranksy et. al. 2016)

•  Achieving adequate pain control

  Ultrasound can also be used to guide hematoma blocks. The hematoma block is a technique wherein the physician injects an anesthetic solution into the hematoma between the fractured bone fragments (see image below). It has been shown to be effective, safe, faster, and uses fewer resources with no significant difference in pain scores when compared to procedural sedation in both adults and children with distal forearm fractures.[6,7]

Clean skin and place a sterile cover over the transducer. Using 5-10cc of 1-2% lidocaine inject into the hematoma between the fractured bone fragments using an 18-22 gauge needle.

Visualization of needle (N) entering between fracture bone fragments (U) (emdocs.net)

Take Home Points

• Ultrasound is most useful in evaluating long bone fractures such as the femur, clavicle, ribs, or distal radius and ulna.

• A reliable alternative to the plain radiograph is the proper six-view method it, with the advantages of being portable and radiation-free.

• Ultrasound can also be reliably used to confirm fracture reduction, as well as for guiding forearm fracture hematoma blocks. 

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Expert Commentary

Thank you for providing a concise summary of the utility of Point-of-care Ultrasound (POCUS) for pediatric forearm fractures.  

I’d like to mention a few key points regarding the use of POCUS for pediatric fracture assessment.

• If you do a lot of adult scanning and not much pediatric scanning it is important to keep in mind that children may not be as cooperative (or stationary) as adults.

  • Smaller children may be afraid of the transducer therefore introducing the transducer to the patient as an object that will not hurt them is key. You should hand the probe to the patient, allow them to touch it and even scan themselves initially in order to get them more comfortable with the probe.

• While the 6-view scan you describe will certainly improve sensitivity, adequate sensitivity can be achieved with a 2-view approach. Additionally, the 6-view technique may be prohibitively time-intensive in a busy Emergency Department.

  • In order to increase sensitivity with the 2-view approach, always start imaging at the point of maximal tenderness, initially in the longitudinal plane with the cortex of the bone parallel to the probe surface. Slide distal and proximal to the point of tenderness. Then rotate the probe 90 degrees to view the cortex in the transverse plane. Fractures are noted as cortical disruptions or step-offs. Fractures are most visible on POCUS when the fracture line is perpendicular to the angle of insonation.

• Another key pearl is to use copious gel in order to optimize the focal point of the image. The focal zone on the screen is the part of the image with the highest resolution secondary to convergence of the US beams. The focal point can be changed depending upon your machine, but is typically no more shallow than about 1-cm below the probe surface, therefore if you place a good layer of gel about 1cm thick, you will place the cortext of the bone at the optimal focal point. Using copious gel is also important in reducing any potential discomfort caused by pressure from the probe.

  • If gel is a limited resource, you can use a water bath as well.

• While POCUS is a wonderful tool, especially for fracture detection, I want you to keep in mind that the sensitivity of POCUS for fractures is the highest (low-mid 90s) for the diaphysis of long bones (femur, humerus, radius and ulna). Sensitivity is significantly lower for detecting fractures of other bones and fractures near joint lines secondary to the curvilinear nature of the metaphysis as well as the presence of cartilaginous epiphyseal plates in children.

  • While POCUS can supplant the use of radiography in austere environments, in a well-resourced emergency department, POCUS should be an adjunct to radiography. In this setting, POCUS can have utility in patients in whom you suspect occult fracture despite negative XRs or for real-time fracture reduction assessment before sedation wears off. Unless you are a pediatric POCUS expert, I would order XR’s as usual for a pediatric patient you suspect has a fracture. In the meantime- continue scanning patients with normal anatomy and documented fractures in order to develop your POCUS expertise! Happy Scanning!

Rachel Haney, MD

NUEM ‘17

Ultrasound Fellow at Massachusetts General Hospital

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How To Cite This Post

[Peer-Reviewed, Web Publication] Chodakowski J, Weygandt L. (2019, April 28). Ultrasound in pediatric distal forearm fractures. [NUEM Blog. Expert Commentary by Haney R]. Retrieved from http://www.nuemblog.com/blog/us-for-fracture

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References

1. Douma-den Hamer, Djoke, et al. "Ultrasound for Distal Forearm Fracture: A Systematic Review and Diagnostic Meta-Analysis." PloS one 11.5 (2016): e0155659.

2. Chaar-Alvarez FM, Warkentine F, Cross K, et al. Bedside ultrasound diagnosis of nonangulated distal forearm fractures in the pediatric emergency department. Pediatr Emerg Care 2011; 27:1027.

3. Herren C, Sobottke R, Ringe MJ, et al. Ultrasound-guided diagnosis of fractures of the distal forearm in children. Orthop Traumatol Surg Res 2015; 101:501.

4. Dubrovsky, Alexander Sasha, et al. "Accuracy of ultrasonography for determining successful realignment of pediatric forearm fractures." Annals of emergency medicine 65.3 (2015): 260-265.

5. Socransky, Steve, et al. "Ultrasound-Assisted Distal Radius Fracture Reduction." Cureus 8.7 (2016).

6. Fathi, M. et al. Ultrasound-guided hematoma block in distal radius fracture reduction: a randomized clinical trial. Emerg Med J. 2014 Jul 12.

7. Bear, David M., et al. "Hematoma block versus sedation for the reduction of distal radius fractures in children." The Journal of hand surgery 40.1 (2015): 57-61.