# pediatric in pain



## Ewok Jerky (Apr 22, 2014)

arrived to find 6 y/o Haitian boy at home with dad.  Hx of sickle cell dz.  Today he stayed home from school because of chest pain.  He is dressed in pajamas, laying on the couch under a blanket watching cartoons.  He is awake and responds apporiatly when prompted, but has a flat affect.  He has Hx of pain in his knees in the morning, sometimes takes motrin.  He has never been hospitalized for sickle cell, and has not been under routine care.

Vitals- BP: 108/60, HR: 110, RR: 18, 94% room air

what next?


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## OnceAnEMT (Apr 22, 2014)

Is the C/C the CP? I'd ask OPQRST on it to see if you can't isolate the differentials a bit, and most definitely do a full head to toe. Pertinent question would be if he has done anything physically strenuous recently, especially at an abnormally high level. As well, I'd ask about fluid intakes. Enough water? Too much soda? Etc. Both of those things are primarily causes for exacerbation of sickle cell trait and anemia.

That's coming from my athletic training student side. Definitely, definitely needs to see a PD MD if he is starting to get involved with sports, or anything other than walking around the house.


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## Ewok Jerky (Apr 22, 2014)

Grimes said:


> Is the C/C the CP? I'd ask OPQRST on it to see if you can't isolate the differentials a bit, and most definitely do a full head to toe. Pertinent question would be if he has done anything physically strenuous recently, especially at an abnormally high level. As well, I'd ask about fluid intakes. Enough water? Too much soda? Etc. Both of those things are primarily causes for exacerbation of sickle cell trait and anemia.
> 
> That's coming from my athletic training student side. Definitely, definitely needs to see a PD MD if he is starting to get involved with sports, or anything other than walking around the house.



CC is indeed chest pain.  sudden onset this AM with waking. Unable to charecterize due to limited vocabulary, but able to localize to mid-sternum, increased with respiration, and severe with palpation. Does not radiate.  No releaving factors.

No recent strenuous activity, per dad he goes to school and acts like a normal 6 y/o old. Fluid intake is adequate, decreased appetite over the last 24 hours.

any more info you want? any thoughts on DDx?


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## OnceAnEMT (Apr 22, 2014)

Any discoloration or swelling anywhere? Not sure if that would occur, just would be interesting if it did.

1. Partial blockage somewhere due to sickle cell, but not cardiac, yet. But I don't know why that would be aggravated by palpation.

2. Impact to chest while being a normal 6 y/o resulted in bruise or even structural damage (aggravated by palp)

Those two kind of cover what you've given. Just because he has sickle cell doesn't mean its involved. Knee pain, all kiddos have history of joint pain. Not sure of anything else. Whatcha got?

Actually, all that said, what are the lung sounds? Any cough since pain started? Ask to cough, any production?


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## Ewok Jerky (Apr 22, 2014)

Grimes said:


> Any discoloration or swelling anywhere? Not sure if that would occur, just would be interesting if it did.
> 
> 1. Partial blockage somewhere due to sickle cell, but not cardiac, yet. But I don't know why that would be aggravated by palpation.
> 
> ...



No discoloration or swelling or signs of trauma.  Lung sounds reveal rales in RUL, reports a productive cough x2 days.  

I can tell you more but I will wait and see if anyone else chimes in.


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## OnceAnEMT (Apr 22, 2014)

Going to put my Dx in the spoiler.

Redacted, forum doesnt support BB Coded spoiler. Will pm to you later.


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## FLdoc2011 (Apr 22, 2014)

Fever?  Rash?   Sick contacts?


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## Ewok Jerky (Apr 22, 2014)

FLdoc2011 said:


> Fever?  Rash?   Sick contacts?



Good questions. T = 100.1, no rash, no sick contacts at home but he goes to elementary school.


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## teedubbyaw (Apr 22, 2014)

Does he have that febrile gaze? Boogers, noisy breathing?

4 lead? BGL? Cap?

Judging by the picture you gave, he doesn't seem to be in severe pain. Maybe some more info on TICLS (pat) if that's not the case. 

Definitely get him on O2.


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## mycrofft (Apr 22, 2014)

Pain with palpation in the absence of chest auscultation raises the index favoring blunt trauma or some other sort of stern-costal inflammation. MAYBE high esophageal or mediastinal issue? Was it firm palpation, sternal or lateral palpation, etc?


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## Angel (Apr 22, 2014)

id want to know about sputum production...in my head im leaning toward him being sick. chest pain all the time or only when he coughs?

o2 for sure, ecg 


is he behaving normally according to dad? you mentioned flat affect; is he lethargic at all?


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## mycrofft (Apr 22, 2014)

beano said:


> CC is indeed chest pain.  sudden onset this AM with waking. Unable to charecterize due to limited vocabulary, but able to localize to mid-sternum, increased *with* respiration, and severe _*with*_ palpation. Does not radiate.  No releaving factors.
> 
> No recent strenuous activity, per dad he goes to school and acts like a normal 6 y/o old. Fluid intake is adequate, decreased appetite over the last 24 hours.
> 
> any more info you want? any thoughts on DDx?



This is more _tenderness_ with residual discomfort (aka "pain"). Coughing would be agonizing.

Hm. Too low_* if midline*_ to be foreign object. We're talking the neighborhood of the mediastium and esophagus and heart.


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## KellyBracket (Apr 23, 2014)

Great discussion so far. I'm not going to leap in with my DDx yet, but I will say that I'm glad no one has suggested that this patient could follow up with their PMD for this.

Clue to my DDx: One of the pediatrics professors in med school would say that you only need to ask the parent in this situation (sickle & CP, fever) one question - Does he/she have any allergies?


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## Ewok Jerky (Apr 23, 2014)

Great questions and great thinking guys.  I posted this for 2 reasons, first to teach something I just learned and  second to see how you guys would work up this kid.  You all covered the basics great, just one last question before I give you the diagnosis (err, diagnosis we worked with)

Should you 12-lead him?


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## teedubbyaw (Apr 23, 2014)

beano said:


> Should you 12-lead him?



Sure. He could be having a vaso-occlusive crisis.


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## mycrofft (Apr 24, 2014)

OP come back!:sad:


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## teedubbyaw (Apr 24, 2014)

mycrofft said:


> OP come back!:sad:



They just posted...


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## Ewok Jerky (Apr 24, 2014)

mycrofft said:


> OP come back!:sad:



sorry guys, been finishing up my peeds rotation and had to put together a lecture, + its been pretty busy during the days.

anyways.  this kid came into our community hospital ED with CP, Hx of sickle cell dz.  has not been under routine care, never been hospitalized for pain although he usually experiences pain in his knees and sometimes arms. we admitied him and gave morphine in escelating doses to control his pain.  we were unsuccessful overnight and the next day.  we called the city childrens hosp for consult and found out that sickle cell kids arent even managed by the heme-onc fellow, they are managed by sickle cell specialist.  althought th ekid showed no obvious signs of infection, there was concern for Acute Chest Syndrome (wich I had never heard of).

 Acute chest syndrome is caused by an infection (typically PNA) which leads to hypoxia which leads to increased sickling which leads to vaso-occlusion and eventually death. I changed a few deets of this case to make it look more like acute chest. 

 I was thinking about how this might present in the field.  Although there is not much you can treat for pre-hospital, this might be something to stow in the back of your brain if you ever run into a sicke cell kid.  Great differentials also!

*and yes, run a 12-lead*


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## mycrofft (Apr 24, 2014)

Wikipedia's  article, with citations:

http://en.wikipedia.org/wiki/Acute_chest_syndrome

Vaso-occlusive


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## FLdoc2011 (Apr 24, 2014)

Did the initial admitting hospital not recognize acute chest syndrome in a kid with sickle cell?


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## FLdoc2011 (Apr 24, 2014)

And I wouldn't just say that infection causes it as it has several causes with some complex pathogenesis.

Fat emboli from bone/marrow infarction, multiple viral/bacterial causes, and in a good number of cases the cause is frankly not known.


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## mycrofft (Apr 24, 2014)

FLdoc2011 said:


> And I wouldn't just say that infection causes it as it has several causes with some complex pathogenesis.
> 
> Fat emboli from bone/marrow infarction, multiple viral/bacterial causes, and in a good number of cases the cause is frankly not known.



Darned syndromes, can't get them to commit to one etiology over another!

I hated treating inmates with sickle cell, jail is not where you treat something like that, yet these people really needed to have their "time out".


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## Ewok Jerky (Apr 24, 2014)

FLdoc2011 said:


> Did the initial admitting hospital not recognize acute chest syndrome in a kid with sickle cell?



Community hospital that doesn't see a lot of sickle cell. Not sure we missed it, because it was in our differential. We transferred him because we didn't know if we were treating ACS or a pain crisis.

Correction: there is indeed more than 1 etiology of Acute Chest Syndrome.


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## FLdoc2011 (Apr 24, 2014)

Even if a community hospital setting it's one of the more known sickle cell emergencies, especially in pediatrics which an ER doc would/should be familiar with.


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## Ewok Jerky (Apr 24, 2014)

FLdoc2011 said:


> Even if a community hospital setting it's one of the more known sickle cell emergencies, especially in pediatrics which an ER doc would/should be familiar with.





Familiar with and manage/treat in house?


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## FLdoc2011 (Apr 24, 2014)

I'm assuming they were admitted to a pediatrics service?   

Yes,  assuming they were physicians that went to med school and completed a residency in some pediatrics related field they should be familiar with one of the more common and more serious complications of sickle cell disease in children.   

Now if just a small pediatric service with no ICU level care and just not equipped then yea transfer out, but I would think they would recognize that from admission and not a day or so into it think, "oh crap, he has acute chest syndrome"


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## KellyBracket (Apr 25, 2014)

Even if it looks like a "simple pain crisis" at first, both children and adults with sickle cell disease can develop acute chest over the next few days.

No one suggested it here, but it bears some emphasis - just _don't_ let the parents of a febrile kid with sickle cell (± chest pain) decline transport to the ED, if you can help it. Most of those kids are getting admitted, and they are all getting antibiotics (preferably with 1 hour of arrival). 

These are very high-risk patients, probably worse than most traumas or MIs you transport.


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## chaz90 (May 1, 2014)

Interesting call tonight that immediately made me think of this thread. I had never heard of acute chest syndrome prior to reading this thread and then doing some additional research a few days ago. Had a call at about 0100 tonight for a 6 YOF with "very bad" pinpoint chest pain and a mild fever. Pain located mid sternally and is reproducible to palpation and inspiration, along with waking her from sleep this evening. Patient stayed home from school yesterday with stomach pain, and has no history of recent trauma or illness. Patient has a history of sickle cell anemia and presented very stably with no abnormalities in vital signs or remainder of physical exams. 

Honestly, I have no idea whether this patient will end up having acute chest syndrome at all or of it will be completely unrelated, but I'm actually glad they transported her and I will call for some follow-up out of curiosity later.


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## Ewok Jerky (May 1, 2014)

YES! Mission accomplished, thanks Chaz90


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## teedubbyaw (May 1, 2014)

chaz90 said:


> Interesting call tonight that immediately made me think of this thread. I had never heard of acute chest syndrome prior to reading this thread and then doing some additional research a few days ago. Had a call at about 0100 tonight for a 6 YOF with "very bad" pinpoint chest pain and a mild fever. Pain located mid sternally and is reproducible to palpation and inspiration, along with waking her from sleep this evening. Patient stayed home from school yesterday with stomach pain, and has no history of recent trauma or illness. Patient has a history of sickle cell anemia and presented very stably with no abnormalities in vital signs or remainder of physical exams.
> 
> Honestly, I have no idea whether this patient will end up having acute chest syndrome at all or of it will be completely unrelated, but I'm actually glad they transported her and I will call for some follow-up out of curiosity later.




What was the pre hospital treatment?


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## mycrofft (May 1, 2014)

I'm dense. Exactly why is this syndrome tender to palpp?


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## chaz90 (May 1, 2014)

teedubbyaw said:


> What was the pre hospital treatment?



Based on the current stability, BLS monitor and transport. Like I said, I don't even know if this was acute chest syndrome or not. In all honesty, it was a very routine call on first glance and one I wouldn't have thought anything of if I hadn't recently learned about acute chest syndrome. This might be a classic case of thinking zebras when I heard hoofbeats, but I'm glad to at least have this in my list of differentials.


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## OnceAnEMT (May 1, 2014)

mycrofft said:


> I'm dense. Exactly why is this syndrome tender to palpp?



And at that, I'm wondering what type of pain.


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## Chupathangy (May 7, 2014)

KellyBracket said:


> Clue to my DDx: One of the pediatrics professors in med school would say that you only need to ask the parent in this situation (sickle & CP, fever) one question - Does he/she have any allergies?



Why is that?


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## KellyBracket (May 8, 2014)

Chupathangy said:


> Why is that?



Because they are getting antibiotics. You just need to make sure they don't have an allergy to e.g. penicillin.


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## Chupathangy (May 8, 2014)

KellyBracket said:


> Because they are getting antibiotics. You just need to make sure they don't have an allergy to e.g. penicillin.



Oh ok. Thats what I was leaning towards. Thanks.


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## Margarida Giese (Jun 23, 2014)

Hi, I really appreciate the topic about recommendations about this matter. It really helps a lot during emergency cases.


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