PECARN Pediatric Head Injury/Trauma Algorithm

Presenter: Dr. Tara Kopp, Pediatric EM

• SNOUT – sensitivity = rule out
• SPIN – specificity = rule in
• PECARN = cohort of 20+ large academic institutions that combine to produce academic research studies
• ciTBI = clinically important traumatic brain injury
• Want to have high sensitivity = screening test = rule out ciTBI and need for CT scan

PECARN Criteria:

• Age: <2 yo or >2 yo
• GCS ≤14 or signs of basilar skull fracture or signs of AMS
  • AMS = Agitation, somnolence, repetitive questioning, or slow response to verbal communication
• History of LOC or history of vomiting or severe headache or severe mechanism of injury
  • Small children = severe fall > 3 ft
  • Older children = severe fall > 5ft

Observation vs CT scan

• Observation usually 4-6 hours; may take into account time from injury
• Children with no PECARN criteria ciTBI predictors = lots of head CTs which could be avoided
• Recommend repeat physical exam prior to discharge if observation

Conclusion:

• Severe injury mechanism
  • Children with isolated severe injury mechanism are at low risk of ciTBI, and many do not require imaging.
• Scalp hematoma
  • Clinicians should use patient age, scalp hematoma location and size, and injury mechanism to determine need for imaging in otherwise asymptomatic children.
• VP shunt
  • Children with VP shunts had higher CT use but similar rates of ciTBI compared with children w/o VP shunts. (limited sample size)

Peritonsillar abscess

Presenter: Dr. Brett Nelson

• Most common deep space infection of head and neck
• Predisposed by previous/recurrent tonsilitis or pharyngitis

Symptoms:

• Odynophagia, drooling, voice change

Evaluation:

• Edematous tonsil, pillars, or soft palate
• Uvula deviation
• Ultrasound
  • Intraoral US with endocavitary probe
  • Submandibular US with linear probe
• CT head/neck w/ contrast

Treatment:

• Needle aspiration – start near superior tonsillar pole, cut needle guard to protect
• Incision and drainage – cut scalpel guard to protect
• Antibiotics alone – Augmentin +/- Clindamycin
• “Quinsy Tonsillectomy” – performed by ENT in severe cases of airway obstruction

Disposition: Usually discharge with ENT follow-up

Sialolithiasis and Suppurative Parotitis

Presenter: Dr. Kyle Stucker

Sialolithiasis:

• Calcium carbonate or phosphate stones of salivary gland in stagnant duct
• Mechanism: Duct stasis, bacterial migrations alter salivary gland pH, altered duct electrolyte concentrations
• 80% occur in submandibular gland
• Usually 5mm; >10-15 mm = “megalith”

Diagnosis:

• Facial swelling, pain, discomfort
• Clinical – stone may be palpated
• CT scan
• Ultrasound

Treatment:

• <5 mm stone
  • Conservative
  • Outpatient therapy and analgesia
  • Gland massage
  • Sialogogues, such as lemon drops
  • Antibiotics if concern for infection
  • ENT referral
• > 5mm
  • Consider ENT consult

Suppurative Parotitis

• Duct infection or infected stone
• Evaluated with CT or US
• Collect cultures if visible purulent discharge

Treatment:

• Augmentin or clindamycin if penicillin allergy
• Admit for IV abx (Unasyn) if concern for sepsis, signs of trismus or airway compromise

Small Group Lecture: ENT Foreign Bodies

Present: Dr. Taylor Strohmaier

Ear foreign body:

• Lidocaine, mineral oil, hydrogen peroxide – anesthesia and kill insect

Removal techniques:

• Irrigation – may utilize IV catheter; contraindicated in TM perforation and button battery
• Forceps – flat or alligator, right angle tool, currette (lighted if available)
• Dermabond + Q-tip – allow glue to become tacky
• Snake pediatric NG tube/foley past to attempt to drag out

Consider otic drops if TM perforation or significant EAC trauma

• Cipro-dex drops
• Dry ear precautions

Consult ENT:

• Unable to remove FB
• Patient requires sedation

Eye foreign body:

Eye exam: EOM, pupils, visual acuity, fluorescein stain, Woods lamp, slit-lamp exam, tonometry, ultrasound, CT scan (may be helpful if concern for metallic FB)

Removal techniques: irrigation, moist Q-tip or cotton swab, 18 g needle on slit-lamp exam, eye burr

Complication of metallic FB: rust ring or corneal perforation (open globe)

• Rust rings can form within only a few hours
• Update Tdap
• Consult ophthalmology

Antibiotic:

• Moxifloxacin (Vigamox), ofloxacin, ciprofloxacin drops
  • Require pseudomonal coverage for contact len wearers
• Erythromycin ointment

Consult ophthalmology if unable to remove FB, visual deficit, concern for open globe, or rust ring

Follow-up with optho – 24-48 hrs

Nasal Foreign Body:

Removal Techniques:

• Mother’s Kiss Technique
• Suctioning
• Forceps with nasal speculum
• Dermabond on Q-tip
• Foley catheter, Fogarty catheter or Katz extractor

Complications:

• Soft tissue injury – epistaxis, septal injury/hematoma, nasopharyngeal trauma
• Barotrauma
• Displacement of FB into airway

Disposition:

• Discharge home following FB removal in uncomplicated cases
• Antibiotics if concern for infection
• ENT consult if unable to remove FB or persistent epistaxis