Badness in Babies. Samuel Reid, MD Pediatric Emergency Medicine Children s Minnesota

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1 Badness in Babies Samuel Reid, MD Pediatric Emergency Medicine Children s Minnesota

2 Case 8 day-old infant transported by EMS with a twelve hour history of vomiting and increasingly poor responsiveness. Born at 36 weeks gestation. No complications.

3 Case EMS transported with blow-by O2. Sternal rubs for apnea.

4 Case PAT = floppy, mottled, intermittent apnea T = 35.8 C. HR = 204 [narrow complex] RR = 24 [irregular] O2 sat = not picking up HEENT AF full Lungs coarse, subcostal retractions CV pulses not palpable, CRT = 4 seconds Abdomen distended Skin no cutaneous injury, petechiae, or vesicles Neuro pupils symmetric, no cry with IV attempts

5 Pediatric Assessment Triangle

6 Case PAT = floppy, mottled, intermittent apnea T = 35.8 C. HR = 204 [narrow complex] RR = 24 [irregular] O2 sat = not picking up HEENT AF full Lungs coarse, subcostal retractions CV pulses not palpable, CRT = 4 seconds Abdomen distended Skin no cutaneous injury, petechiae, or vesicles Neuro pupils symmetric, no cry with IV attempts

7 Differential Diagnosis Sepsis/meningitis HSV Non-accidental trauma Congenital heart disease Surgical abdominal processes Congenital adrenal hyperplasia Inborn errors of metabolism RSV Pertussis

8 IV - O2 - Monitors Cervical spine precautions Oxygen NRB OxyMask HFNC BVM Cardiac monitor Oximeter Capnography IV/IO

9 Airway & Breathing Plan A BVM RSI? ETT cuffed NG/OG FAST 1 view chest/abdomen XR Plan B BVM with oral airway RSI? LMA - size 1 NG/OG FAST 1 view chest/abdomen XR

10 Circulation Plan A IV (think scalp) Labs o POC glucose, electrolytes o Blood culture Cardiac interventions o NS 10 ml/kg IV, repeat if no CHF on CXR o Cardioversion for SVT o PGE1 for CHF o Dobutamine for CHF o Dopamine for non-cardiogenic, fluid-resistant shock o Hydrocortisone for CAH Plan B IO Femoral stick for labs o POC glucose, electrolytes o Blood culture Cardiac interventions o NS 10 ml/kg IO, repeat if no CHF on CXR o Cardioversion for SVT o PGE1 for CHF o Dobutamine for CHF o Dopamine for non-cardiogenic, fluid-resistant shock o Hydrocortisone for CAH

13 Circulation Plan C Umbilical venous line

15 Disability Plan A D10 for hypoglycemia ( 40 mg/dl) 3% saline for hyponatremic SZ Anticonvulsants o Midazolam o Fosphenytoin o Levetiracetam o Phenobarbital o Pyridoxine Mannitol for increased ICP Plan B D10 for hypoglycemia ( 40 mg/dl) 3% saline for hyponatremic SZ Anticonvulsants o Midazolam o Fosphenytoin o Levetiracetam o Phenobarbital o Pyridoxine Mannitol for increased ICP

16 Exposure/Exam Plan A Cefotaxime Ampicillin Acyclovir Acetaminophen for elevated temperature Heating lamp for normal or low temperature INITIATE TRANSPORT Plan B Cefotaxime Ampicillin Acyclovir Acetaminophen for elevated temperature Heating lamp for normal or low temperature INITIATE TRANSPORT

17 Drug Dosing Intervention Cardioversion for SVT PGE1 for CHF Dobutamine for CHF Dopamine for noncardiogenic, fluid-resistant shock Hydrocortisone Midazolam for SZ Fosphenytoin for SZ Levetiracetam for SZ Phenobarbital for SZ Pyridoxine for SZ Dose 1-2 J/kg 0.1 mcg/kg/min IV/IO 2-20 mcg/kg/min IV/IO 2-20 mcg/kg/min IV/IO Hydrocortisone 2 mg/kg IV/IO 0.1 mg/kg IV/IO/IM 20 mg/kg IV/IO/IM mg/kg IV/IO mg/kg 100 mg IV/IO Intervention Dose Mannitol for ICP g/kg IV/IO D10 for hypoglycemia 5-10 ml/kg IV/IO 3% saline for hyponatremia 2-6 ml/kg IV/IO slowly Cefotaxime 50 mg/kg IV/IO/IM Ampicillin 50 mg/kg IV/IO/IM Acyclovir 10 mg/kg IV/IO Acetaminophen 15 mg/kg PR

18 Style Points Cath urine 1. UA 1 ml 2. UC 1 ml Extra blood priorities 1. CBC 0.5 ml 2. Ionized calcium 0.2 ml 3. NH3 0.6 ml 4. 17α-hydroxyprogesterone 0.3 ml 5. Red top CSF 1. Culture 0.5 ml 2. HSV PCR 0.3 ml

19 Definitive Care LP UGI + SBFT Head CT Skeletal survey EEG Echocardiogram Metabolic workup Coagulation studies Viral studies Consultations

20 Key Points Have a plan Have an alternative plan ABCDEs Get POC chemistries Consider Prostaglandin E1 Hydrocortisone Treat with broad spectrum antibiotics and acyclovir regardless of what body fluid samples you can obtain.

21 Twists In Kids: A Torsion Update

22 Schwartz BI, et al. Creation of a composite score to predict adnexal torsion in children and adolescents. J Pediatr Adolesc Gynecol 2018;31:

23 Background The presentation of adnexal torsion is variable and there is no definitive clinical or imaging test. Surgical exploration is the only means by which to verify the diagnosis. Missed adnexal torsion results in loss of the ovary or fallopian tube with resultant impairment in hormonal function and fertility. No prospective data examining clinical features associated with adnexal torsion.

24 Methods Design Prospective cross-sectional study Participants 241 female patients, age 6-21 years Presented with lower abdominal pain and underwent US or CT of the pelvis

25 Methods Intervention Data collection Demographics Potential clinical predictors of torsion 1) Duration of pain 2) Intermittent pain 3) Nausea 4) Vomiting Potential radiographic predictors of torsion 1) Absence of arterial or venous flow 2) Adnexal volume 3) Adnexal volume ratio Data collection Operative findings Pathology reports Final diagnosis

26 Methods Analysis Regression analysis to identify clinical variables independently associated with ovarian torsion Receiver Operator Curve analysis to select and weight variables according to sensitivity and specificity

27 Methods Outcome measure Composite score to predict adnexal torsion

28 Results: Flow of Study Patients 324 patients w/ lower abdominal pain Imaging 241 No imaging 83 Pre-menarchal 46 Post-menarchal 195 GYN surgery 11 Non-GYN surgery 15 No surgery 20 GYN surgery 28 Non-GYN surgery 20 No surgery 147 Non-GYN surgery 27 Torsion 6 No torsion 5 Torsion 10 No torsion 18

29 Regression Analysis Regression analysis is a statistical process that determines the relationship between a dependent variable (e.g. adnexal torsion) and one or more independent predictor variables.

30 Results Factors statistically associated with torsion Vomiting Adnexal volume Adnexal volume ratio Adnexal ratio = volume of affected adnexa/volume of unaffected adnexa Factors not statistically associated with torsion Duration of pain Intermittent nature of pain Nausea Absence of arterial and/or venous flow on Doppler US

Adnexal Blood Flow The main blood supply to the adnexa is from the ovarian artery. A second source of arterial blood comes from a collateral uterine artery.

31 Adnexal Blood Flow The main blood supply to the adnexa is from the ovarian artery. A second source of arterial blood comes from a collateral uterine artery. With torsion, there can still be arterial vascular flow on US because of the dual blood supply. One artery can be twisted and occluded but the other can still supply blood to the ovary. Torsion should be considered if the ovary is enlarged or edematous even if arterial flow is demonstrated.

32 Results: Composite Score Independent risk factor Value Score Pre-menarchal Post-menarchal Vomiting No No 0 Yes Yes 2 Adnexal volume < 6 ml < 105 ml ml 1 > 17 ml > 105 ml 2 Adnexal ratio < 1.25 < > 21 > 21 2 Composite score Total (0-6)

33 Results: Risk of Torsion Composite score Torsion n = 14 No torsion n = (n = 60) 0 100% 1 (n = 49) 0 100% 2 (n = 34 ) 3% 97% 3 (n = 29) 10% 90% 4 (n = 4) 25% 75% 5 (n = 6) 50% 50% 6 (n = 7) 86% 14% Area Under Receiver Operator Curve = = excellent = good = fair = poor = fail

34 Receiver Operating Characteristic Curve A receiver operating characteristic curve (ROC curve) is created by plotting the true positive rate (sensitivity) of a test against the false positive rate (1 specificity) at various threshold settings. The area under the curve measures the ability of the test to correctly classify those with and without the disease.

35 Authors Conclusion Independent predictors of adnexal torsion can reliably be combined into a composite score to identify children and adolescents at risk for adnexal torsion. This score may aid in improving triage and management of these challenging patients.

36 Comments Methodology Selection bias Imaging Surgical exploration (diagnostic gold standard) Clinical application Validation, preferably multicenter, is needed. Best tool currently available My take Score 0 2: Look for alternative diagnoses Score 3 6: Consult gynecologist Selection bias is the selection of individuals, groups or data for analysis in such a way that proper randomization is not achieved, thereby ensuring that the sample obtained is not representative of the population intended to be analyzed.

37 Barbosa JA, et al. Development and initial validation of a scoring system to diagnose testicular torsion in children. J Urology 2013;189:

38 Background Testicular torsion is a time-sensitive emergency for which delay to detorsion is associated with worse outcomes. The clinical presentation of testicular torsion overlaps with the presentation of less dire scrotal conditions. Doppler US examination of the scrotum has high sensitivity and specificity for the diagnosis of testicular torsion, but its completion and interpretation may delay definitive treatment. A sufficiently sensitive and specific clinical score could theoretically decrease ischemic time and preserve testicular viability in patients with testicular torsion.

39 Methods Design Prospective cohort Participants 338 male patients, age 3 months to 18 years, with acute scrotal pain

Methods Intervention History and exam findings recorded by urologist Scrotal US with doppler Operative reports for those undergoing surgical exploration reviewed Clinical variables with low

40 Methods Intervention History and exam findings recorded by urologist Scrotal US with doppler Operative reports for those undergoing surgical exploration reviewed Clinical variables with low inter-observer agreement were excluded from further analysis. Inter-observer agreement measures how much consensus there is when different examiners independently evaluate patients for the same physical finding. If various raters do not agree, assessment of the given finding might not be reliable or valid.

41 Methods Analysis Regression analysis to identify clinical variables independently associated with testicular torsion Receiver Operator Curve analysis to select and weight variables according to sensitivity and specificity

42 Methods Outcome measure Performance characteristics of generated clinical prediction rule

43 Results 51/338 enrolled cases (15%) were ultimately diagnosed with testicular torsion.

44 Results: Regression Analysis Factors statistically associated with torsion Nausea and/or vomiting Testicular swelling High-riding testicle Transverse lie Hard testicle Absent cremasteric reflex Factors statistically associated with torsion but excluded because of poor inter-observer agreement Thick spermatic cord Scrotal skin fixed to testicle

45 Results: ROC Analysis Clinical Variable Points Testicular swelling 2 Hard testicle 2 High-riding testicle 1 Nausea and/or vomiting 1 Absent cremasteric reflex 1 Area under curve = 0.983

46 Results: Score Performance Score Testicular torsion present Testicular torsion absent % % % 3 7% 93% 4 41% 59% 5 100% % % 0

47 Results: Recommended Use Score Risk Recommendation 0-2 Low No US 3-4 Intermediate US 5-7 High To OR without US

48 Authors Conclusion The Testicular Workup for Ischemia and Suspected Torsion (TWIST) score can potentially rule-out testicular torsion in 80% cases, with high positive and negative predictive values for selected cutoffs. US orders would be decreased to 20% of acute scrotum cases. Prospective validation of this scoring system is necessary.

49 Comments Methodology Clinical application Validating studies Sheth KR, et al. J Urol 2016;195: Frohlich LC, et al. Acad Emerg Med 2017;24: Manohar CS, et al. Urol Ann 2018;10:20-23 Time is testicle Will the urologists and the medical-legal system buy it?

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