Treating Special Needs Childrenin the Emergency Room: Enteral Feeding Tubes, Tracheostomy, Ventricular Shunt, Autism | EB Medicine
0

Best Practices In The Emergency Department Management Of Children With Special Needs

Below is a free preview. Log in or subscribe for full access. Or, get a free sample article ED Assessment and Management of Pediatric Acute Mild Traumatic Brain Injury and Concussion:
Please provide a valid email address.

*NEW* Quick Search this issue!

Table of Contents
 
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiology And Pathophysiology
    1. Gastrostomy Tube Types And Indications
    2. Tracheostomy Tube Types And Indications
    3. Ventricular Shunt Types And Indications
    4. Children With Developmental And Behavioral Disabilities
  6. Differential Diagnosis
    1. Gastrostomy And Gastrojejunal Tubes
    2. Tracheostomy Tubes
    3. Ventricular Shunts
    4. Children With Developmental And Behavioral Disabilities
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. General Approach To The Initial Evaluation
  9. Diagnostic Studies
    1. Gastrostomy And Gastrojejunal Tubes
    2. Tracheostomy Tubes
    3. Ventricular Shunts
      1. Computed Tomography And Magnetic Resonance Imaging
      2. Plain Radiography
      3. Tapping The Shunt
      4. Shunt Flow Studies
      5. Other Diagnostic Studies
  10. Treatment
    1. Gastrostomy And Gastrojejunal Tubes
      1. Gastrostomy Tube Replacement
      2. Gastrojejunal Tube Replacement
      3. Removal Of Gastrojejunal Tube Obstruction
      4. Correcting Leakage At The Stoma Site
      5. Infection
    2. Tracheostomy Tubes
    3. Ventricular Shunts
      1. Shunt Obstruction
      2. Shunt Infection
      3. Abdominal Pseudocyst
      4. Children With Developmental And Behavioral Disabilities
      5. Nonpharmacologic Measures
      6. Sedative/Analgesia Considerations
      7. Painful Procedures
        • Topical Anesthetics
        • Opioids And Benzodiazepines
        • Ketamine
      8. Nonpainful Procedures
        • Benzodiazepines
        • Barbiturates
        • Propofol
        • Dexmedetomidine
        • Etomidate
        • Chloral Hydrate
        • Nitrous Oxide
      9. Alternate Routes Of Sedation/Analgesia
  11. Special Circumstances
  12. Controversies And Cutting Edge
    1. Ventricular Shunt Flow
  13. Disposition
    1. Gastrostomy And Gastrojejunal Tubes
  14. Summary
  15. Risk Management Pitfalls In The Management Of Children With Special Needs
  16. Time- And Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathways
    1. Clinical Pathway For Management Of Pediatric Patients With Tracheostomy Malfunction (Hypoxia, Respiratory Distress, Cyanosis)
    2. Clinical Pathway For Management Of Pediatric Patients With Suspected Cerebroventricular Shunt Malfunction (Headache, Vomiting, Altered Behavior)
    3. Clinical Pathway For Management Of Pediatric Patients With Developmental Disorders Who Require A Procedure
  19. Tables
    1. Table 1. Differential Diagnosis Of Gastrostomy Tube Complications
    2. Table 2. Differential Diagnosis Of Tracheostomy-Related Complications
    3. Table 3. Differential Diagnosis Of Ventricular Shunt Complications
    4. Table 4. Nonpharmacological Measures To Reduce Anxiety In Children With Developmental Delay Or Autism Spectrum Disorder
  20. References

Abstract

Children with special needs have a wide variety of physical and developmental challenges. These children often have medical devices, subtle presentations, and behavioral or psychiatric issues that demand consideration when delivering emergency care. Some of the more common issues include the evaluation and management of complications in devices such a gastrostomy/jejunostomy feeding tubes, cerebroventricular shunts, and tracheostomy tubes, as well as impediments to the performance of common emergency procedures (eg, laceration repair, sedation for imaging) on children with developmental or behavioral disorders. This review will examine each of these circumstances and provide guidance on the best approaches to managing these patients.

Case Presentations

A 7-year-old girl with an intellectual disability arrives to the ED with her parents, who state that the girl has been lethargic all day, is not tolerating her gastrostomy tube feeds, and is having some leakage and redness around the exit site of her tube. She has been vomiting nonbloody, nonbilious material with every feeding attempt. Her parents describe her breathing as “harder than usual,” with an increase in her baseline home oxygen requirement. In addition, they noticed some scant blood from her tracheostomy tube after suctioning thick whitish-yellow secretions from it. Her urine output has decreased from 4 times per day to 1 time per day. She has a low-grade fever to 38.2°C. Her past medical history includes premature birth at 25 weeks with a complicated NICU stay, including hypoxic-ischemic encephalopathy, grade IV intraventricular hemorrhage requiring placement of a ventriculoperitoneal shunt, gastrostomy tube placement, prolonged intubation with chronic lung disease, tracheostomy tube placement, a seizure disorder, and significant developmental delay (the child is nonverbal) with static encephalopathy. With her many problems, how do you evaluate the cause of this child’s vomiting, lethargy, and difficulty breathing?

A 3-year-old boy with Down syndrome is brought to the ED 1 hour after pulling out his percutaneous endoscopically placed gastrostomy tube, which was placed 2 years ago. The mother believes he broke the balloon when he yanked the tube out. His past medical history includes repair of a ventricular septal defect and failure to thrive. What are the best ways to manage the dislodged tube?

An 8-year-old boy with autism arrives to the ED with a 5-cm scalp laceration extending to the temporal area of the head that he sustained after falling from a 5-foot height. His parents report a loss of consciousness for 1 to 2 minutes as well as abnormal behavior. You decide he needs a CT scan to evaluate for intracranial injury, and the laceration will need to be repaired. How do you approach the sedation of this child so he can safely and effectively undergo the interventions he requires?

Introduction

Children with special healthcare needs are defined as children “who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.”1 An estimated 12% to 18% of children in the United States have special needs,2-5 and they account for 5 times the number of doctor visits as children without special needs.

Children with pervasive neurodevelopment disorders, autistic spectrum disorder (ASD), and developmental disorders, and behaviorally complex children are frequent patients in the emergency department (ED). These children often have complex medical histories and various comorbid conditions that complicate their care. In addition, these children may be limited in their capacity for cooperation and communication, making diagnosis and treatment difficult. In a Canadian study of patients with ASD who presented to the ED at a tertiary care center, 33 of 160 patients (20%) were admitted, 71% had an emergency triage score of 1 to 2 (suggesting high-acuity problems), and 79% had > 1 chronic health problem. Furthermore, the study found that patients with ASD comprised 2% of all ED visits. Parents of children with developmental disorders may also be more likely to use the ED as their medical home, especially if they do not have a well-established relationship with a primary care provider. In a survey of ED usage by children in the United States with developmental disorders, children with ≥ 3 ED visits were found to report less access to primary care sources than patients with no ED visits, who often reported well-established primary care.7

The term “children with special needs” covers a broad array of children, including those born prematurely, children who suffered hypoxia in the perinatal period, children with developmental and behavioral conditions, and medically complex patients, such as those with congenital cardiac and brain disorders, genetic disorders, inborn errors of metabolism, and mitochondrial diseases. This review focuses on identification and management of common problems with enteral feeding tubes, tracheostomies, and ventricular shunts, and will include a discussion on performing emergency procedures in children with autism and other cognitive disabilities.

Critical Appraisal Of The Literature

An extensive literature search was conducted on PubMed using combinations of the following search terms: special needs, children, disabled, technology dependent, epidemiology, prevalence, emergency department, gastrostomy, percutaneous endoscopic, compli-cations, jejunostomy, migration, ventriculoperitoneal shunt, infection, cellulitis, malfunction, tracheostomy, tracheoinnominate fistula, tracheitis, mucociliary clearance, emergency procedure, bleeding, sedation, autism, developmental delay, virtual reality, child life specialist, autism, behavior, procedure, management, acute setting, imaging, MRI, agitation , and aggressive . Only articles whose subjects included children aged 0 to 18 years were identified. Abstracts were reviewed for relevance to the topic. Supporting articles were gathered from related articles and the reference lists of review articles. All relevant articles were selected, reviewed, and included in the bibliography. Overall, there is a dearth of literature in this patient population, and more studies are needed.

Risk Management Pitfalls In The Management Of Children With Special Needs

  1. “The G tube is leaking around the exit site. I’ll just upsize it to close the hole.”
    Upsizing a leaking G tube runs the risk of expanding the size of the stoma, which may lead to further expansion of the hole. Instead, pull the tube toward you until the tube is flush against the anterior abdominal wall. Make sure the balloon is inflated and functioning. If these maneuvers fail, consult with the service (usually surgery) that placed the tube.

  2. “The blood from the tracheostomy was flowing pretty heavily when he got here, but now it’s stopped, his hemoglobin is normal, and the dad told me he was suctioning him every hour before it started. I’m going to send him home. The ear, nose, and throat specialist doesn’t need to be called in.”
    Tracheoinnominate fistula is a life-threatening condition that can’t be missed. Often there will be a sentinel bleed prior to a clinically important larger bleed. An ear, nose, and throat specialist should evaluate the tracheostomy with bronchoscopy if the amount of blood is impressive, even if it has since stopped. Tracheoinnominate fistula, bleeding granulomatous tissue, and tracheitis are all possible diagnoses, or excessive bleeding could be caused by aggressive suctioning.

  3. “The patient’s mom told me that she put the dislodged G tube back in, and she’s been feeding him through it, so I don’t need to check its placement.”
    At the very least, pull back stomach secretions from the tube, and check the pH to ensure that the tube is, in fact, in the stomach. Make sure that the tube is amenable to a parent’s replacing it, such as a G tube with balloon, and not a GJ tube or one without a balloon.

  4. “He just started vomiting, so he’ll probably develop diarrhea soon. It’s probably just a virus.”
    Whether this patient has a shunt or feeding tube or a history of abdominal surgery, maintain a lower threshold to work up the child with special needs who is vomiting. This could represent shunt malfunction, tube obstruction, intestinal obstruction, medication side effects, nonaccidental head trauma, or decompensation of a metabolic problem.

  5. “The head CT scan shows small ventricles, so the symptoms must not be related to the VP shunt.”
    A subset of patients with VP shunts has nochange in ventricle size on CT, despite having a malfunctioning shunt. If the patient demonstrates symptoms of shunt obstruction, consult with neurosurgery to evaluate the patient, regardless of results of brain CT.

  6. “He has tachycardia and fever, but he is an older child with special needs, so we don’t have to worry about his having a serious bacterial infection.”
    Sepsis is more common in children with special needs than in the general pediatric population. Although sepsis is not a common diagnosis among children with special needs, abnormal vital signs should not be ignored in this population.

  7. “This child with autism just needs a couple stitches in his lip. I don’t want to sedate him, be-cause it’s too risky, so I’ll just hold him down.”
    Children with autism respond to procedural sedation as well as children who do not have autism using similar amounts of sedation medication. Follow usual protocols, avoid polypharmacy, and be ready with backup airway maneuvers.

  8. “The CT is normal, and the VP shunt flow was normal when the neurosurgeon tapped it, so it must not be the shunt causing the headaches, lethargy, and vomiting.”
    In a small prospective study, 64% of the children had symptoms of shunt malfunction with a normal CT and normal shunt tap.70 Do not ignore signs of elevated ICP.

  9. “I can’t find a source of fever in this patient who has a VP shunt, but we don’t need to tap the shunt, since he had his last revision 1 month ago.”
    Ninety percent of VP shunt infections will occur within the first 6 months after placement or revision. Children who have fever within the first month are at highest risk for VP shunt infection, so the shunt should be tapped to investigate for infection if no other obvious source is present.

  10. “I don’t want the family to have to watch this fragile child with special needs go through this code. This family has been through enough.”
    Children with special needs are no different from other children, and parental presence should be offered in these situations. Importantly, you should determine early in the resuscitation efforts what the end-of-life care preferences are, including Allow Natural Death, DNR, or variations of these plans.


Tables

Table 1. Differential Diagnosis Of Gastrostomy Tube Complications

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study will be included in bold type following the references cited in this paper, as determined by the author, will be noted by an asterisk (*) next to the number of the reference.

  1. McPherson M, Arango P, Fox H, et al. A new definition of children with special health care needs. Pediatrics . 1998;102(1 Pt 1):137-140. (Maternal and Child Health Bureau’s Division of Services for Children With Special Health Care Needs (DSCSHCN) work group consensus opinion)
  2. Bramlett MD, Blumberg SJ. Prevalence of children with special health care needs in metropolitan and micropolitan statistical areas in the United States. Matern Child Health J . 2008;12(4):488-498. (National survey data; 373,055 children)
  3. Newacheck PW, Strickland B, Shonkoff JP, et al. An epidemiologic profile of children with special health care needs. Pediatrics . 1998;102(1 Pt 1):117-123. (Survey-based study; 30,032 completed respondents)
  4. van Dyck PC, Kogan MD, McPherson MG, et al. Prevalence and characteristics of children with special health care needs. Arch Pediatr Adolesc Med . 2004;158(9):884-890. (Telephone survey; families of 38,866 children with special health care needs aged < 18 years)
  5. Williams TV, Schone EM, Archibald ND, et al. A national assessment of children with special health care needs: prevalence of special needs and use of health care services among children in the military health system. Pediatrics . 2004;114(2):384-393. (Representative random sample survey; 7483 beneficiaries eligible for care in the military health system)
  6. Cohen-Silver JH, Muskat B, Ratnapalan S. Autism in the emergency department. Clin Pediatr (Phila) . 2014;53(12):1134- 1138. (Retrospective chart review; 160 patients)
  7. Lin SC, Margolis B, Yu SM, et al. The role of medical home in emergency department use for children with developmental disabilities in the United States. Pediatr Emerg Care . 2014;30(8):534-539. (Multivariate logistic regression analysis on national survey data)
  8. Martinez DA, Ginn-Pease ME, Caniano DA. Sequelae of antireflux surgery in profoundly disabled children. J Pediatr Surg . 1992;27(2):267-271. (Retrospective review; 198 surgeries)
  9. Barnhart DC, Hall M, Mahant S, et al. Effectiveness of fundoplication at the time of gastrostomy in infants with neurological impairment. JAMA Pediatr . 2013;167(10):911-918. (Retrospective observational cohort study; 42 hospitals, 4163 patients)
  10. Mathus-Vliegen EM, Koning H, Taminiau JA, et al. Percutaneous endoscopic gastrostomy and gastrojejunostomy in psychomotor retarded subjects: a follow-up covering 106 patient years. J Pediatr Gastroenterol Nutr . 2001;33(4):488-494. (Prospective longitudinal study; 68 patients)
  11. Kremer B, Botos-Kremer AI, Eckel HE, et al. Indications, complications, and surgical techniques for pediatric tracheostomies--an update. J Pediatr Surg . 2002;37(11):1556-1562. (Systematic review)
  12. de Trey L, Niedermann E, Ghelfi D, et al. Pediatric tracheotomy: a 30-year experience. J Pediatr Surg . 2013;48(7):1470-1475. (Retrospective review; 119 patients)
  13. Posner JC. Acute care of the child with a tracheostomy. Pediatr Emerg Care . 1999;15(1):49-54. (Review)
  14. Harrington JW, Allen K. The clinician’s guide to autism. Pediatr Rev . 2014;35(2):62-78. (Review)
  15. Ben-Sasson A, Hen L, Fluss R, et al. A meta-analysis of sensory modulation symptoms in individuals with autism spectrum disorders. J Autism Dev Disord . 2009;39(1):1-11. (Meta-analysis)
  16. Boyd BA, Baranek GT, Sideris J, et al. Sensory features and repetitive behaviors in children with autism and developmental delays. Autism Res . 2010;3(2):78-87. (Observational analysis; 109 children)
  17. Brewster BD, Weil BR, Ladd AP. Prospective determination of percutaneous endoscopic gastrostomy complication rates in children: still a safe procedure. Surgery . 2012;152(4):714- 719. (Prospective longitudinal study; 103 patie nts)
  18. Gauderer MW. Percutaneous endoscopic gastrostomy: a 10-year experience with 220 children. J Pediatr Surg . 1991;26(3):288-292. (Retrospective review, 220 children)
  19. Marin OE, Glassman MS, Schoen BT, et al. Safety and efficacy of percutaneous endoscopic gastrostomy in children. Am J Gastroenterol. 1994;89(3):357-361. (Retrospective review; 70 children)
  20. Kimber CP, Khattak IU, Kiely EM, et al. Peritonitis following percutaneous gastrostomy in children: management guidelines. Aust N Z J Surg . 1998;68(4):268-270. (Retrospective review; 8 cases of peritonitis out of 130 surgeries)
  21. Sridhar AV, Nichani S, Luyt D, et al. Candida peritonitis: a rare complication following early dislodgement of percutaneous endoscopic gastrostomy tube. J Paediatr Child Health . 2006;42(3):145-146. (Case report)
  22. Naiditch JA, Lautz T, Barsness KA. Postoperative complications in children undergoing gastrostomy tube placement. J Laparoendosc Adv Surg Tech A . 2010;20(9):781-785. (Retrospective review; 159 patients)
  23. * Saavedra H, Losek JD, Shanley L, et al. Gastrostomy tube-related complaints in the pediatric emergency department: identifying opportunities for improvement. Pediatr Emerg Care . 2009;25(11):728-732. (Retrospective cross-sectional study; 181 visits, 77 patients)
  24. Novotny NM, Vegeler RC, Breckler FD, et al. Percutaneous endoscopic gastrostomy buttons in children: superior to tubes. J Pediatr Surg . 2009;44(6):1193-1196. (Retrospective review; 223 surgeries [110 tubes, 113 buttons])
  25. Cahill AM, Baskin KM, Kaye RD, et al. Transmural migration of gastrostomy tube retention discs. Pediatr Radiol . 2004;34(2):143-147. (Retrospective review; 8 cases of migration out of 300 procedures performed)
  26. Singh RR, Eaton S, Cross KM, et al. Management of a complication of percutaneous gastrostomy in children. Eur J Pediatr Surg. 2013;23(1):76-79. (Retrospective review; 20 cases of buried bumper)
  27. Lin HS, Ibrahim HZ, Kheng JW, et al. Percutaneous endoscopic gastrostomy: strategies for prevention and management of complications. Laryngoscope . 2001;111(10):1847-1852. (Retrospective review; 103 adult patients, 11 minor complications)
  28. Kazi S, Gunasekaran TS, Berman JH, et al. Gastric mucosal injuries in children from inflatable low-profile gastrostomy tubes. J Pediatr Gastroenterol Nutr . 1997;24(1):75-78. (Case series)
  29. Weiss B, Fradkin A, Ben-Akun M, et al. Upper gastrointestinal bleeding due to gastric ulcers in children with gastrostomy tubes. J Clin Gastroenterol . 1999;29(1):48-50. (Case series, 4 children)
  30. Joshi AS, Tanna N, Elmaraghy CA, et al. Nonsurgical treatment of tracheoinnominate fistula in the pediatric population. Arch Otolaryngol Head Neck Surg . 2007;133(3):294-296. (Case report and literature review)
  31. Allan JS, Wright CD. Tracheoinnominate fistula: diagnosis and management. Chest Surg Clin N Am . 2003;13(2):331-341. (Review)
  32. Grant CA, Dempsey G, Harrison J, et al. Tracheo-innominate artery fistula after percutaneous tracheostomy: three case reports and a clinical review. Br J Anaesth . 2006;96(1):127-131. (Case series and literature review)
  33. * Piatt JH Jr, Garton HJ. Clinical diagnosis of ventriculoperitoneal shunt failure among children with hydrocephalus. Pediatr Emerg Care . 2008;24(4):201-210. (2 multicenter prospective randomized controlled clinical trials; 248 shunt failures)
  34. Stone JJ, Walker CT, Jacobson M, et al. Revision rate of pediatric ventriculoperitoneal shunts after 15 years. J Neurosurg Pediatr . 2013;11(1):15-19. (Retrospective review; 234 procedures, 64 patients)
  35. Livingston JH, McCullagh HG, Kooner G, et al. Bradycardia without associated hypertension: a common sign of ventriculo-peritoneal shunt malfunction. Childs Nerv Syst . 2011;27(5):729-733. (Retrospective review; 52 patients)
  36. Bourgeois M, Sainte-Rose C, Cinalli G, et al. Epilepsy in children with shunted hydrocephalus. J Neurosurg . 1999;90(2):274-281. (Retrospective review; 802 children)
  37. Johnson DL, Conry J, O’Donnell R. Epileptic seizure as a sign of cerebrospinal fluid shunt malfunction. Pediatr Neurosurg . 1996;24(5):223-227. (Retrospective review; 817 patients)
  38. Kim TY, Stewart G, Voth M, et al. Signs and symptoms of cerebrospinal fluid shunt malfunction in the pediatric emergency department. Pediatr Emerg Care . 2006;22(1):28-34. (Retrospective review; 352 patients)
  39. Lee TT, Uribe J, Ragheb J, et al. Unique clinical presentation of pediatric shunt malfunction. Pediatr Neurosurg . 1999;30(3):122-126. (Retrospective review; 70 consecutive VP shunt revisions, 65 patients)
  40. Martinez-Lage JF, Martos-Tello JM, Ros-de-San Pedro J, et al. Severe constipation: an under-appreciated cause of VP shunt malfunction: a case-based update. Childs Nerv Syst . 2008;24(4):431-435. (Case series)
  41. Aldrich EF, Harmann P. Disconnection as a cause of ventriculoperitoneal shunt malfunction in multicomponent shunt systems. Pediatr Neurosurg . 1990;16(6):309-311. (Retrospective review; 41 cases of disconnected shunts out of 275 shunt failures)
  42. Adams DJ, Rajnik M. Microbiology and treatment of cerebrospinal fluid shunt infections in children. Curr Infect Dis Rep . 2014;16(10):427. (Review)
  43. Lee JK, Seok JY, Lee JH, et al. Incidence and risk factors of ventriculoperitoneal shunt infections in children: a study of 333 consecutive shunts in 6 years. J Korean Med Sci . 2012;27(12):1563-1568. (Retrospective cohort analysis; 333 consecutive VP shunt infections)
  44. Rogers EA, Kimia A, Madsen JR, et al. Predictors of ventricular shunt infection among children presenting to a pediatric emergency department. Pediatr Emerg Care . 2012;28(5):405- 409. (Retrospective cohort; 130 patients)
  45. Tuan TJ, Thorell EA, Hamblett NM, et al. Treatment and microbiology of repeated cerebrospinal fluid shunt infections in children. Pediatr Infect Dis J . 2011;30(9):731-735. (Retrospective review; 31 children with recurrent shunt infections)
  46. Mobley LW 3rd, Doran SE, Hellbusch LC. Abdominal pseudocyst: predisposing factors and treatment algorithm. Pediatr Neurosurg . 2005;41(2):77-83. (Retrospective review; 64 cases in 34 patients)
  47. Roitberg BZ, Tomita T, McLone DG. Abdominal cerebrospinal fluid pseudocyst: A complication of ventriculoperitoneal shunt in children. Pediatr Neurosurg . 1998;29(5):267-273. (Retrospective review; 27 patients)
  48. Yousfi MM, Jackson NS, Abbas M, et al. Bowel perforation complicating ventriculoperitoneal shunt: report and review. Gastrointest Endosc . 2003;58(1):144-148. (Case report)
  49. Pohlman GD, Wilcox DT, Hankinson TC. Erosive bladder perforation as a complication of ventriculoperitoneal shunt with extrusion from the urethral meatus: case report and literature review. Pediatr Neurosurg . 2011;47(3):223-226. (Case report)
  50. Mohammadi A, Hedayatiasl A, Ghasemi-Rad M. Scrotal migration of a ventriculoperitoneal shunt: a case report and review of literature. Med Ultrason . 2012;14(2):158-160. (Case report)
  51. Glatstein M, Constantini S, Scolnik D, et al. Ventriculoperitoneal shunt catheter protrusion through the anus: case report of an uncommon complication and literature review. Childs Nerv Syst . 2011;27(11):2011-2014. (Case report)
  52. Glatstein MM, Roth J, Scolnik D, et al. Late presentation of massive pleural effusion from intrathoracic migration of a ventriculoperitoneal shunt catheter: case report and review of the literature. Pediatr Emerg Care . 2012;28(2):180-182. (Case report)
  53. Wei Q, Qi S, Peng Y, et al. Unusual complications and mechanism: migration of the distal catheter into the heart- -report of two cases and review of the literature. Childs Nerv Syst . 2012;28(11):1959-1964. (Case series)
  54. Charalambides C, Sgouros S. Spontaneous knot formation in the peritoneal catheter: a rare cause of ventriculoperitoneal shunt malfunction. Pediatr Neurosurg . 2012;48(5):310-312. (Case report)
  55. Buie T, Campbell DB, Fuchs GJ III, et al. Evaluation, diagnosis, and treatment of gastrointestinal disorders in individuals with ASDs: a consensus report. Pediatrics . 2010;125 Suppl 1:S1-S18. (Consensus expert opinion)
  56. Balamuth F, Weiss SL, Neuman MI, et al. Pediatric Severe sepsis in U.S. children’s hospitals. Pediatr Crit Care Med . 2014;15(9):798-805. (Observational cohort study; 25,236 patients)
  57. * Mitchell RB, Hussey HM, Setzen G, et al. Clinical consensus statement: tracheostomy care. Otolaryngol Head Neck Surg . 2013;148(1):6-20. (Consensus guideline)
  58. Spiegelman L, Asija R, Da Silva SL, et al. What is the risk of infecting a cerebrospinal fluid-diverting shunt with per-cutaneous tapping? J Neurosurg Pediatr . 2014;14(4):336-339. (Retrospective review; 266 children, 542 shunt taps)
  59. Lee YH, Park EK, Kim DS, et al. What should we do with a discontinued shunt? Childs Nerv Syst . 2010;26(6):791-796. (Retrospective review; 22 patients)
  60. Sivaganesan A, Krishnamurthy R, Sahni D, et al. Neuroimaging of ventriculoperitoneal shunt complications in children. Pediatr Radiol . 2012;42(9):1029-1046. (Review)
  61. Sellin JN, Cherian J, Barry JM, et al. Utility of computed tomography or magnetic resonance imaging evaluation of ventricular morphology in suspected cerebrospinal fluid shunt malfunction. J Neurosurg Pediatr . 2014;14(2):160-166. (Retrospective review; 42 patients)
  62. Alhilali LM, Dohatcu AC, Fakhran S. Evaluation of a limited three-slice head CT protocol for monitoring patients with ventriculoperitoneal shunts. AJR Am J Roentgenol . 2013;201(2):400-405. (Retrospective cohort; 231 CT scans, 128 patients)
  63. Rozovsky K, Ventureyra EC, Miller E. Fast-brain MRI in children is quick, without sedation, and radiation-free, but beware of limitations. J Clin Neurosci . 2013;20(3):400-405. (Retrospective review; 50 patients)
  64. Wait SD, Lingo R, Boop FA, et al. Eight-second MRI scan for evaluation of shunted hydrocephalus. Childs Nerv Syst . 2012;28(8):1237-1241. (Retrospective review; 42 patients)
  65. O’Neill BR, Pruthi S, Bains H, et al. Rapid sequence magnetic resonance imaging in the assessment of children with hydro-cephalus. World Neurosurg . 2013;80(6):e307-e312. (Retrospective review; 50 patients, 119 MRI scans)
  66. Zorc JJ, Krugman SD, Ogborn J, et al. Radiographic evaluation for suspected cerebrospinal fluid shunt obstruction. Pediatr Emerg Care . 2002;18(5):337-340. (Retrospective review; 233 patients, 60 shunt malfunction requiring surgery)
  67. Blumstein H, Schardt S. Utility of radiography in suspected ventricular shunt malfunction. J Emerg Med . 2009;36(1):50-54. (Retrospective review; 205 patient encounters)
  68. Iskandar BJ, McLaughlin C, Mapstone TB, et al. Pitfalls in the diagnosis of ventricular shunt dysfunction: radiology reports and ventricular size. Pediatrics . 1998;101(6):1031-1036. (Retrospective review; 68 patients, 100 shunt revisions)
  69. McNatt SA, Kim A, Hohuan D, et al. Pediatric shunt malfunction without ventricular dilatation. Pediatr Neurosurg . 2008;44(2):128-132. (Retrospective review; 177 patients, 287 shunt revisions)
  70. Sunami K, Saeki N, Sunada S, et al. Slit ventricle syndrome after cyst-peritoneal shunting for temporal arachnoid cyst in children--a clinical entity difficult to detect on neuroimaging study. Brain Dev . 2002;24(8):776-779. (Case series)
  71. Rekate HL. Shunt-related headaches: the slit ventricle syndromes. Childs Nerv Syst . 2008;24(4):423-430. (Review)
  72. * Rocque BG, Lapsiwala S, Iskandar BJ. Ventricular shunt tap as a predictor of proximal shunt malfunction in children: a prospective study. J Neurosurg Pediatr . 2008;1(6):439-443. (Prospective consecutive cases; 68 shunt taps, 51 patients)
  73. Vernet O, Farmer JP, Lambert R, et al. Radionuclide shuntogram: adjunct to manage hydrocephalic patients. J Nucl Med . 1996;37(3):406-410. (Retrospective review; 47 children)
  74. Chung JJ, Yu JS, Kim JH, et al. Intraabdominal complications secondary to ventriculoperitoneal shunts: CT findings and review of the literature. AJR Am J Roentgenol. 2009;193(5):1311-1317. (Retrospective review; 70 adult patients)
  75. Showalter CD, Kerrey B, Spellman-Kennebeck S, et al. Gastrostomy tube replacement in a pediatric ED: frequency of complications and impact of confirmatory imaging. Am J Emerg Med . 2012;30(8):1501-1506. (Retrospective review; 237 children)
  76. Wu TS, Leech SJ, Rosenberg M, et al. Ultrasound can accurately guide gastrostomy tube replacement and confirm proper tube placement at the bedside. J Emerg Med. 2009;36(3):280-284. (Prospective pilot; 3 children, 7 adults)
  77. Soscia J, Friedman JN. A guide to the management of common gastrostomy and gastrojejunostomy tube problems. Paediatr Child Health . 2011;16(5):281-287. (Retrospective review; 560 adult patients)
  78. Schapiro GD, Edmundowicz SA. Complications of percutaneous endoscopic gastrostomy. Gastrointest Endosc Clin N Am . 1996;6(2):409-422. (Review)
  79. Hayashi AH, Lau HY, Gillis DA. Topical sucralfate: effective therapy for the management of resistant peristomal and perineal excoriation. J Pediatr Surg . 1991;26(11):1279-1281. (Case series; 15 patients)
  80. Fascetti-Leon F, Gamba P, Dall’Oglio L, et al. Complications of percutaneous endoscopic gastrostomy in children: results of an Italian multicenter observational study. Dig Liver Dis . 2012;44(8):655-659. (Multicenter prospective study; 239 children)
  81. Broadley KJ. Beta-adrenoceptor responses of the airways: for better or worse? Eur J Pharmacol . 2006;533(1-3):15-27. (Review)
  82. James HE, Walsh JW, Wilson HD, et al. Prospective randomized study of therapy in cerebrospinal fluid shunt infection. Neurosurgery . 1980;7(5):459-463. (Prospective randomized study; 30 patients)
  83. Schreffler RT, Schreffler AJ, Wittler RR. Treatment of cerebrospinal fluid shunt infections: a decision analysis. Pediatr Infect Dis J . 2002;21(7):632-636. (Decision analysis using data from prior studies)
  84. Mustafa MM, Mertsola J, Ramilo O, et al. Increased endotoxin and interleukin-1 beta concentrations in cerebrospinal fluid of infants with coliform meningitis and ventriculitis associated with intraventricular gentamicin therapy. J Infect Dis . 1989;160(5):891-895. (Prospective study; 21 infants)
  85. Arnell K, Enblad P, Wester T, et al. Treatment of cerebrospinal fluid shunt infections in children using systemic and intraventricular antibiotic therapy in combination with externalization of the ventricular catheter: efficacy in 34 consecutively treated infections. J Neurosurg . 2007;107(3 Suppl):213-219. (Prospective randomized study; 34 patients)
  86. James HE, Bradley JS. Management of complicated shunt infections: a clinical report. J Neurosurg Pediatr . 2008;1(3):223- 228. (Prospective nonrandomized study; 18 patients)
  87. Klimo P Jr, Thompson CJ, Ragel BT, et al. Antibiotic-impregnated shunt systems versus standard shunt systems: a meta-and cost-savings analysis. J Neurosurg Pediatr . 2011;8(6):600- 612. (Meta-analysis and cost-saving analysis)
  88. Parker SL, Anderson WN, Lilienfeld S, et al. Cerebrospinal shunt infection in patients receiving antibiotic-impregnated versus standard shunts. J Neurosurg Pediatr . 2011;8(3):259- 265. (Systematic review)
  89. Gursky B, Kestler LP, Lewis M. Psychosocial intervention on procedure-related distress in children being treated for lac-eration repair. J Dev Behav Pediatr . 2010;31(3):217-222. (Nonrandomized nonblinded prospective study; 24 patients)
  90. Stevenson MD, Bivins CM, O’Brien K, et al. Child life intervention during angiocatheter insertion in the pediatric emergency department. Pediatr Emerg Care . 2005;21(11):712- 718. (Randomized prospective study; 149 children)
  91. Scarpinato N, Bradley J, Kurbjun K, et al. Caring for the child with an autism spectrum disorder in the acute care setting. J Spec Pediatr Nurs . 2010;15(3):244-254. (Review)
  92. Backman B, Pilebro C. Visual pedagogy in dentistry for children with autism. ASDC J Dent Child . 1999;66(5):325-331, 294. (Observational analysis; 16 subjects)
  93. Dial S, Silver P, Bock K, et al. Pediatric sedation for procedures titrated to a desired degree of immobility results in unpredictable depth of sedation. Pediatr Emerg Care. 2001;17(6):414-420. (Retrospective review; 301 sedations)
  94. Cote CJ, Wilson S, American Academy of Pediatrics, et al. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics . 2006;118(6):2587-2602. (Consensus guideline)
  95. * Kannikeswaran N, Mahajan PV, Sethuraman U, et al. Sedation medication received and adverse events related to sedation for brain MRI in children with and without developmental disabilities. Paediatr Anaesth . 2009;19(3):250-256. (Retrospective review; 486 patients)
  96. Kannikeswaran N, Sethuraman U, Sivaswamy L, et al. Children with and without developmental disabilities: sedation medication requirements and adverse events related to sedation. Pediatr Emerg Care . 2012;28(10):1036-1040. (Prospective observational age-matched case-control study; 210 children [70 developmentally delayed])
  97. Ross AK, Hazlett HC, Garrett NT, et al. Moderate sedation for MRI in young children with autism. Pediatr Radiol. 2005;35(9):867-871. (Retrospective review; 83 children)
  98. Elwood T, Hansen LD, Seely JM. Oropharyngeal airway diameter during sedation in children with and without developmental delay. J Clin Anesth . 2001;13(7):482-485. (Retrospective review; 40 children)
  99. Maxwell LG, Yaster M. The myth of conscious sedation. Arch Pediatr Adolesc Med . 1996;150(7):665-667. (Editorial)
  100. Harman S, Zemek R, Duncan MJ, et al. Efficacy of pain control with topical lidocaine-epinephrine-tetracaine during lac-eration repair with tissue adhesive in children: a randomized controlled trial. CMAJ . 2013;185(13):E629-E634. (Randomized placebo-controlled blinded trial; 221 children)
  101. Zempsky WT, Bean-Lijewski J, Kauffman RE, et al. Needle-free powder lidocaine delivery system provides rapid effective analgesia for venipuncture or cannulation pain in children: randomized, double-blind Comparison of Venipuncture and Venous Cannulation Pain After Fast-Onset Needle-Free Powder Lidocaine or Placebo Treatment trial. Pediatrics . 2008;121(5):979-987. (Randomized double-blind study; 579 children)
  102. Shah S, Shah S, Apuya J, et al. Combination of oral ketamine and midazolam as a premedication for a severely autistic and combative patient. J Anesth . 2009;23(1):126-128. (Case report)
  103. Zier JL, Doescher JS. Seizures temporally associated with nitrous oxide administration for pediatric procedural sedation. J Child Neurol . 2010;25(12):1517-1520. (Case series)
  104. Moon YE. Paradoxical reaction to midazolam in children. Korean J Anesthesiol . 2013;65(1):2-3. (Commentary)
  105. Golparvar M, Saghaei M, Sajedi P, et al. Paradoxical reaction following intravenous midazolam premedication in pediatric patients - a randomized placebo controlled trial of ketamine for rapid tranquilization. Paediatr Anaesth . 2004;14(11):924- 930. (Prospective randomized placebo-controlled trial; 706 children, 24 paradoxical reactions)
  106. Malviya S, Voepel-Lewis T, Tait AR, et al. Pentobarbital vs chloral hydrate for sedation of children undergoing MRI: efficacy and recovery characteristics. Paediatr Anaesth . 2004;14(7):589-595. (Prospective randomized controlled trial)
  107. Hollman GA, Elderbrook MK, VanDenLangenberg B. Results of a pediatric sedation program on head MRI scan success rates in procedure duration times. Clin Pediatr (Phila) . 1995;34(6):300-305. (Prospective study; 437 children)
  108. Bernal B, Grossman S, Gonzalez R, et al. FMRI under sedation: what is the best choice in children? J Clin Med Res . 2012;4(6):363-370. (Prospective randomized study; 100 patients)
  109. Akhlaghpoor S, Shabestari AA, Moghdam MS. Low dose of rectal thiopental sodium for pediatric sedation in spiral computed tomography study. Pediatr Int . 2007;49(3):387-391. (Prospective observational study; 90 children)
  110. Wu J, Mahmoud M, Schmitt M, et al. Comparison of propofol and dexmedetomidine techniques in children undergoing magnetic resonance imaging. Paediatr Anaesth . 2014;24(8):813- 818. ( Prospective randomized study; 95 children)
  111. Fodale V, La Monaca E. Propofol infusion syndrome: an overview of a perplexing disease. Drug Saf . 2008;31(4):293- 303. (Review)
  112. Parke TJ, Stevens JE, Rice AS, et al. Metabolic acidosis and fatal myocardial failure after propofol infusion in children: five case reports. BMJ. 1992;305(6854):613-616. (Case series; 5 children)
  113. Lubisch N, Roskos R, Berkenbosch JW. Dexmedetomidine for procedural sedation in children with autism and other behavior disorders. Pediatr Neurol . 2009;41(2):88-94. (Retrospective review; 315 patients)
  114. Li YW, Ma L, Sui B, et al. Etomidate with or without flumazenil anesthesia for stem cell transplantation in autistic children. Drug Metabol Drug Interact . 2014;29(1):47-51. (Prospective randomized double-blind study; 40 autistic children)
  115. Delgado J, Toro R, Rascovsky S, et al. Chloral hydrate in pediatric magnetic resonance imaging: evaluation of a 10-year sedation experience administered by radiologists. Pediatr Radiol . 2014;45(1):108-114. (Retrospective review; 1703 patients)
  116. Zier JL, Liu M. Safety of high-concentration nitrous oxide by nasal mask for pediatric procedural sedation: experience with 7802 cases. Pediatr Emerg Care . 2011;27(12):1107-1112. (Prospective observational study; 7802 children)
  117. Pasaron R, Burnweit C, Zerpa J, et al. Nitrous oxide procedural sedation in non-fasting pediatric patients undergoing minor surgery: a 12-year experience with 1,058 patients. Pediatr Surg Int . 2015;31(2):173-180. (Retrospective review; 1058 children sedated for minor surgery)
  118. Mekitarian Filho E, de Carvalho WB, Gilio AE, et al. Aerosolized intranasal midazolam for safe and effective sedation for quality computed tomography imaging in infants and children. J Pediatr. 2013;163(4):1217-1219. (Prospective observational study; 58 children)
  119. Saunders M, Adelgais K, Nelson D. Use of intranasal fentanyl for the relief of pediatric orthopedic trauma pain. Acad Emerg Med . 2010;17(11):1155-1161. (Prospective nonblinded interventional trial; 81 patients)
  120. Borland M, Jacobs I, King B, et al. A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med . 2007;49(3):335-340. (Prospective randomized double-blinded placebo-controlled; 76 children)
  121. Bahetwar SK, Pandey RK, Saksena AK, et al. A comparative evaluation of intranasal midazolam, ketamine and their combination for sedation of young uncooperative pediatric dental patients: a triple blind randomized crossover trial. J Clin Pediatr Dent . 2011;35(4):415-420. (3-stage crossover trial; 45 patients)
  122. Kyrkou M, Harbord M, Kyrkou N, et al. Community use of intranasal midazolam for managing prolonged seizures. J Intellect Dev Disabil . 2006;31(3):131-138. (Observational study, 131 subjects [51 children])
  123. Hibbard RA, Desch LW, American Academy of Pediatrics Committee on Child Abuse and Neglect, et al. Maltreatment of children with disabilities. Pediatrics . 2007;119(5):1018-1025. (Clinical report)
  124. Jones L, Bellis MA, Wood S, et al. Prevalence and risk of violence against children with disabilities: a systematic review and meta-analysis of observational studies. Lancet . 2012;380(9845):899-907. (Meta-analysis and systematic review; 17 studies)
  125. Sullivan PM, Knutson JF. Maltreatment and disabilities: a population-based epidemiological study. Child Abuse Negl . 2000;24(10):1257-1273. (Database analysis)
  126. Nandyal R, Owora A, Risch E, et al. Special care needs and risk for child maltreatment reports among babies that graduated from the neonatal intensive care. Child Abuse Negl . 2013;37(12):1114-1121. (Retrospective review; 2463 infants)
  127. Jaudes PK, Mackey-Bilaver L. Do chronic conditions increase young children’s risk of being maltreated? Child Abuse Negl . 2008;32(7):671-681. (Longitudinal study; 101,189 children aged < 6 years)
  128. Ayoub CC, Schreier HA, Keller C. Munchausen by proxy: presentations in special education. Child Maltreat . 2002;7(2):149-159. (Case series; 9 children)
  129. Elvik SL, Berkowitz CD, Nicholas E, et al. Sexual abuse in the developmentally disabled: dilemmas of diagnosis. Child Abuse Negl . 1990;14(4):497-502. (Case reports; 35 female children)
  130. Kvam MH. Sexual abuse of deaf children. A retrospective analysis of the prevalence and characteristics of childhood sexual abuse among deaf adults in Norway. Child Abuse Negl . 2004;28(3):241-251. (Retrospective questionnaire; 1150 deaf adults)
  131. Madsen JR, Abazi GS, Fleming L, et al. Evaluation of the ShuntCheck noninvasive thermal technique for shunt flow detection in hydrocephalic patients. Neurosurgery . 2011;68(1):198- 205. (Prospective observational study; 20 shunts)
Publication Information
Authors

Solomon Behar, MD; John Cooper, DO

Publication Date

June 2, 2015

Content you might be interested in
Already purchased this course?
Log in to read.
Purchase a subscription

Price: $449/year

140+ Credits!

Money-back Guarantee
Get A Sample Issue Of Emergency Medicine Practice
Enter your email to get your copy today! Plus receive updates on EB Medicine every month.
Please provide a valid email address.