Penetrating neck injuries in children are rare—but when they happen, the stakes are high. In this episode of PEM Currents: The Pediatric Emergency Medicine Podcast, we explore the clinical pearls behind “no-zone” management, how to distinguish hard and soft signs, when to image versus operate, and why airway always comes first. Get ready for a focused, evidence-based deep dive into pediatric neck trauma.

Stone ME Jr, Christensen P, Craig S, Rosengart M. Management of penetrating neck injury in children: A review of the National Trauma Data Bank. Red Cross Annals. 2017;32(4):171–177. doi:10.1016/j.rcsann.2017.04.003

Callcut RA, Inaba K. Penetrating neck injuries: Initial evaluation and management. UpToDate. Waltham, MA: UpToDate Inc. [Accessed June 24, 2025]. Available from: https://www.uptodate.com

Note: This transcript was partially completed with the use of the Descript AI and the Chat GPT 4o AI

Welcome to PEM Currents: The Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski, and in this episode we are diving into a high-stakes but fortunately rare topic in pediatric trauma — penetrating neck injuries. Now these injuries make up less than 1% of all pediatric trauma, but when they occur, they demand precision and vigilance in terms of diagnosis and management.

As you know, the neck packs some vital organs, vessels, the airway, esophagus, and nerves into a tiny little area, so even a seemingly minor wound can injure multiple structures.

Now you remember — way back when — where you learned about the zones of the neck, and this is the traditional teaching, which chopped the neck up into three zones.

You’ve got Zone I, which is the area between the clavicle and cricoid. You’ve got the subclavian arteries and vein, the carotid, and the apices of the lungs.

Now, you may recall some teaching that you got in medical school or residency where the management was dictated by which zone was injured. And admittedly, a lot of this evidence is in adults, and more penetrating trauma is seen in adults as well.

But now practice is leaning towards the “no zone” approach, where imaginary lines on the skin surface are not dictating management as much as presentation, symptoms, and deciding when to go to the OR versus using CT angiography.

So let’s talk about mechanisms of injury for a minute.

Toddlers can injure their neck when they fall with something in their mouth, like pencils or chopsticks.

So low-velocity mechanisms dominate pediatric penetrating neck injuries. Force matters, because depth and tissue cavitation decide the overall injury pattern.

In terms of assessing the patient with a penetrating neck injury, it all starts with the ABCs.

Is the patient’s airway patent? Are they protecting and maintaining it?

For breathing, patients should be breathing comfortably with no distress.

For circulation, if the wound is bleeding, apply direct pressure. Some surgeons will use a Foley balloon tamponade method if they need to stop bleeding before going to the operating room.

Patients will need large bore IVs and fluids — and especially blood product resuscitation.

Only immobilize the C-spine if a patient has neurologic deficits or a high injury mechanism.

You may have also heard of hard signs and soft signs in terms of the parlance of managing penetrating neck injury.

In general, hard signs mean go to the operating room.

So here are some hard signs:

Soft signs include:

A large pediatric series showed that 50 to 70% of children with hard signs did need operative repair.

So I alluded to this paradigm at the beginning of the episode — the “no zone” strategy.

For stable children with no hard signs, CT angiography is the gold standard.

Make sure you always get a chest X-ray as well, since penetrating neck injuries can injure the apices of the lungs or thoracic structures.

Also, if the CTA is negative but you still have suspicion for injury to the aerodigestive tract, you can do a water-soluble contrast esophagram or flexible endoscopy.

Plain films — yes, you can assess the C-spine and look for radiopaque foreign bodies, but again, if you truly have a child that is stable and has no hard signs, CTA is the gold standard.

If you follow this, you can cut non-therapeutic neck explorations in half without missing any injuries.

If you do have a neck wound that you have to manage before the surgeons can get to it: direct pressure first.

The Foley balloon tamponade method is where you take an 18 to 20 French catheter, place it into the wound, inflate the balloon with 10 to 15 milliliters of water, and then clamp it.

I wouldn’t necessarily do this in a Level 1 trauma center — I have surgeons available — but it might be useful if you have to transport a kid quickly to a trauma center.

Never, ever, ever pull an impaled object out of the neck in the emergency department.

Now, superficial injuries with the platysma intact get routine closure.

So here’s some pediatric-specific pearls, again, because these are really rare.

Kids have a small airway, and soft tissues swell quickly, so there’s a low threshold for securing the airway.

Kids have low blood volume and don’t tolerate hemorrhage as well.

And unfortunately, some neck wounds are self-inflicted, so make sure you address mental health concerns after the child is stabilized.

Alright. So let’s bring it all home. What are some key take-home points?

That’s all for this episode. I hope you found it useful — especially since these injuries are less common, but can be incredibly impactful.

If you enjoyed the content, or want to hear something different about pediatric trauma, reach out and let me know — I’ll take an email, a comment on the blog, a social media message.

And please — as my 13-year-old would encourage me to say — like, rate, and review.

Share this episode and the podcast with the folks you work with — and not just physicians in the emergency department. I think we all deserve to learn about how we manage injuries in children.

The post PODCAST: Penetrating Neck Injuries children first appeared on האיגוד הישראלי לרפואה דחופה.

Reference: Arnold CG, et al. Performance of individual criteria of the Pediatric Emergency Care Applied Research Network (PECARN) intraabdominal injury prediction rule. Acad Emerg Med. Jan 2025

Date: May 7, 2025

Dr. Sandi Angus

Guest Skeptic : Dr. Sandi Angus is a Paediatric and Adult Emergency Medicine Registrar in the Shrewsbury and Telford Hospital NHS Trust. She is passionate about paediatric EM, wellbeing and medical education.

Case: A ten-year-old boy presents to your emergency department (ED) after being involved in a motor vehicle collision at high speed. Emergency Medical Service (EMS) tells you that he was properly restrained. His parents were also in the vehicle and are currently being brought to the ED as well. He appeared a bit dazed initially, but he has had a Glasgow Coma Scale (GCS) score of 15 throughout transport. Your primary survey is unremarkable. He complains of some abdominal pain, although you note a soft abdomen on exam and no seatbelt sign. As you complete your secondary survey, he vomits once, which is non-bloody. A medical trainee working with says to you, “He says his stomach hurts and threw up. Do you think we need to CT scan his abdomen?”

Background: Intra-abdominal injury (IAI) in children is a significant concern for emergency physicians. This is particularly true in cases of blunt trauma. Although relatively uncommon compared to adults, IAIs in children can be life-threatening. We have to identify them early and manage them appropriately.

The organs most frequently injured include the spleen, liver, and kidneys, but any abdominal organ can be affected​. Diagnosing IAIs in pediatric patients poses a unique challenge. Children often present with subtle clinical findings, and the physical examination can be unreliable due to factors such as altered mental status, distracting injuries, or the child’s inability to articulate their symptoms​.

Imaging modalities like computed tomography (CT) are the gold standard for diagnosis, but CT use must be balanced against the risks of ionizing radiation. Traditionally, clinicians relied heavily on their clinical gestalt, but this approach can miss injuries or lead to unnecessary imaging. The risks of CT imaging are not inconsequential. Children are more radiosensitive than adults, and for each  abdominal or pelvic scan, the lifetime risks of cancer are 1 per 500 scans, irrespective of the age at exposure. However, this is actually very small compared with the background risk of developing cancer in a lifetime, which is 1 in 3, so if your scan is clinically justified, the benefit is likely to outweigh the potential harm [1].

To improve diagnostic accuracy and minimize unnecessary CT scans, clinical decision rules (CDRs) or “tools” have been developed. One such tool, the Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rule for intra-abdominal injuries, identifies children at very low risk of clinically important IAIs, aiming to safely reduce CT utilization​ [2-3]. This rule was composed of seven variables, all of which could be collected on history and physical exam. There was no need for labs or imaging in this decision rule.

These seven variables were:

If all seven variables were negative, the child was at very low risk of having intra-abdominal injury requiring intervention and the decision rule recommended against a CT scan.

Despite the benefits of existing decision rules, the question remains how best to apply these tools when only one or two PECARN criteria are positive—a clinical gray zone not well characterized in earlier validation studies. Understanding the individual performance of PECARN rule components in predicting IAI is crucial for refining decision-making in pediatric trauma care.

Reference: Arnold CG, et al. Performance of individual criteria of the Pediatric Emergency Care Applied Research Network (PECARN) intraabdominal injury prediction rule. Acad Emerg Med. Jan 2025

Authors’ Conclusions: “Few children with blunt torso trauma and one or two PECARN predictor variables present have IAIAI. Those with GCS score <14, however, are at highest risk for IAI.”

Quality Checklist for Clinical Decision Rules:

Results: The original study included 7,542 children with blunt torso trauma across six emergency departments. Of those children, 2,986 (39.6%, 95% CI 38.5 to 40.7) had one or two PECARN positive variables. The median age was 9.8 years and slightly over half (56%) were male. CT scans were obtained in 1236 (41%) of the patients.

Primary Outcome: Of the 1,639 patients who had one variable positive, 21 (1.3%, 95% CI 0.8-2) had intra-abdominal injuries undergoing acute intervention. Of the 1347 who had two variables positive, 27 (2%, 95% CI 1.3-2.9) had intra-abdominal injuries undergoing acute intervention.

Secondary Outcome: Of those 2986 patients enrolled, 227 (7.6%, 95% CI 6.7-8.6) had intra-abdominal injuries.

They also broke it down by each individual variable and how many patients were diagnosed with intra-abdominal injury and intra-abdominal injury undergoing acute intervention. GCS≤14 was the most important individual predictor variable for intra-abdominal injury undergoing acute intervention.

Inclusion Criteria:

It’s important to review the inclusion criteria from the original study because we do not think this clinical decision rule should be applied indiscriminately to every child with abdominal trauma.

A large proportion of the children included in the original study had some pretty severe mechanisms of injury (32% from motor vehicle collisions, 19% were struck by a vehicle, and 13% due to fall from height. Be careful in applying this clinical decision tool to less severe mechanisms.

They excluded patients who had injury that occurred over 24 hours ago. Many of us may have encountered a patient in the emergency department who complains of belly pain from a blunt abdominal injury a day ago and were perhaps seen at an urgent care facility or tried to wait it out. Although they were not part of the patient population in this study, would it be inappropriate to use this clinical decision tool on those patients?

Partial Verification Bias:

In this secondary analysis, only around 40% of patients included had CT scans. What about those who did not?

In the original derivation study, there was one patient with a splenic laceration who returned after being discharged from the ED without imaging who underwent splenic artery embolization. It is possible that some of these patients who did not undergo CT scan still had intra-abdominal injuries that were missed.

This does highlight the primary outcome that they defined as IAI undergoing acute intervention. It is arguably more patient oriented, they missed some IAI but maybe it was not clinically significant. I’ve admitted low grade splenic or liver laceration to the hospital who were observed without any intervention except a repeat hemoglobin before being sent home.

Spectrum Bias:

Subpopulations with only 1–2 rule variables may not fully represent all blunt trauma presentations​. This study only looked at the risk of IAI if one or two variables were positive. Table 5 demonstrates the proportion of children with IAI with two positive variables. Be cautious in that some combinations of these two variables included very few patients.

What happens as you add more variables (>2), and does it matter which variables are positive?

They excluded 2,357 (31%) of patients in the original study because they had more than one positive variable. In that study, 203 children had intra-abdominal injuries undergoing acute interventions. We know there is a proportion of children who can have more variables present and still not have intra-abdominal injury requiring acute intervention.

It is also important to remember that not all variables are created equal. In this study, no patients with the positive single variable of: abdominal pain, vomiting, abnormal breath sounds, or abdominal tenderness had intra-abdominal injury undergoing acute intervention.

Comparison to Clinical Gestalt:

Our FOAMed friend, Dr. Justin Morgenstern, at First10EM thinks clinical decision rules are ruining medicine. Is this clinical decision rule too obvious? Would you be thinking about performing a CT scan if all seven predictor variables were negative without the decision rule? How does this compare to clinical gestalt?

There was another secondary analysis of the same original PECARN study that compared the decision rule with clinicians recorded suspicion of IAI (<1, 1-5, 6-10, 11-50, >50%). The CDR had higher sensitivity 97% compared to clinicians 82.8%, but the clinicians had higher specific 78.7% vs 42.5% [4].

A third of low-risk patients by clinical suspicion still got CT scans, so we see that suspicion for intraabdominal injury did not correlate with the ordering of CTs. We are unsure of the reasons why clinicians chose to obtain the CT even if the suspicion was low.

Adjunct Workup for Intra-abdominal Injury:

One of the strengths of this PECARN clinical decision tool is that all of these variables are things you get from the history and physical examination alone. But are there other things we can use to help risk-stratify children with blunt abdominal injury?

Blood tests, including hemoglobin, lipase, and liver enzymes? The evidence for the use of lab tests is mixed. Hemoglobin measurement is not particularly reliable in the setting of acute blood loss. The sensitivity, specificity, PPV, and NPV of these lab tests are quite variable.

The evidence for FAST is mixed as well [5-9]. It is dependent on operator skill. Unfortunately, a negative FAST scan in pediatrics does not necessarily mean that there’s no significant intra-abdominal injury, just as in adults. The specificity of it is better- so if you see free-fluid in the context of trauma and hemodynamic instability, it’s blood until proven otherwise. However, the sensitivity is poor – Children can still have abdominal injuries without free fluid, although it can be improved by doing serial scanning [10].  There’s still a lot of ongoing research on this topic.

And finally, there is the option of observation in the ED or hospital for serial exams as well.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusion.

Case Resolution: During the boy’s stay in the ED, you and the trainee assessed him multiple times. His reported abdominal pain seems to improve, and he does not have any further episodes of emesis. Your repeat examinations reassure you that the chances of him having a clinically significant intra-abdominal injury are low. His aunt arrives at the ED. You fill her in on the patient’s ED course, and she takes the patient home.

Clinical Application: The PECARN clinical decision tool can be used to risk-stratify children presenting with blunt intra-abdominal injury. If the child is negative for all seven variables, there is a very low chance of them having an intraabdominal injury that requires urgent intervention. Even if one or two of the variables are positive, this does not necessarily mean that the child needs to undergo a CT scan. Use this decision tool in conjunction with your clinical judgement.

What Do I Tell My Trainee? I’m glad you asked that question. There are several ways a child presenting with blunt intra-abdominal injury can be evaluated. Those include lab tests, ultrasound, CT scans, serial exams and observation. The PECARN clinical decision tool risk stratifies these children based on seven variables from the history and physical examination. Even if one or two of these variables are positive, this doesn’t mean we automatically need to put the child through the scanner. Let’s continue to re-evaluate him while he is under our care in the emergency department.

References:

The post PODCAST: Light Em Up Up Up (CT) or Not for Pediatric Blunt Abdominal Trauma? first appeared on האיגוד הישראלי לרפואה דחופה.

Reference:  St Peter, et al. Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomized noni-inferiority trial. The Lancet. Jan 2025

Date: March 19, 2025

Dr. Camille Wu

Guest Skeptic: Dr. Camille Wu is a paediatric surgeon based at Sydney Children’s Hospital where she is the Head of Department. She is also on the Training Committee of Paediatric Surgery for Australia and New Zealand.

Case: A 10-year-old boy presents to the emergency department (ED) with his parents. He started having abdominal pain yesterday and did not want to eat. Today, his abdominal pain worsened, and he developed a fever. On examination, he looks uncomfortable and is tender to palpation in the right lower quadrant. You tell the parents that his examination is concerning for appendicitis. You order an ultrasound that demonstrates a dilated and non-compressible appendix. You consult the surgery team and both of you come to speak with the family. His parents tell you, “His sister was diagnosed with appendicitis during the Covid pandemic. At that time, she was admitted to the hospital but just treated with antibiotics. She was able to go home and has done well since that time. Do you think he needs surgery, or can he be treated with antibiotics as well?”

Background: Acute appendicitis is one of the most common pediatric surgical complaints that we encounter in the ED. Traditionally, appendicectomy has been the gold standard for treatment, based on its effectiveness in preventing complications such as perforation, abscess formation, and peritonitis​. This is typically done laparoscopically through a few small incisions.

The concept of non-operative treatment of appendicitis (NOTA) with antibiotics has gained interest over the past decade. This has been supported by growing evidence suggesting that some cases of uncomplicated appendicitis may resolve without surgery​.

We have covered NOTA before on the SGEM that included some meta-analyses, randomized controlled trials, and observational studies.

The results have been mixed. Some of these studies have suggested that antibiotic therapy is non-inferior to surgical management while other studies have suggested antibiotic therapy did not meet criteria for non-inferiority compared to appendectomy. Most of these studies were conducted in the adult population with fewer studies conducted in children. The question remains:

To cut or not to cut?

Reference:  St Peter, et al. Appendicectomy versus antibiotics for acute uncomplicated appendicitis in children: an open-label, international, multicentre, randomized noni-inferiority trial. The Lancet. Jan 2025

Authors’ Conclusions: Based on cumulative failure rates and a 20% non-inferiority margin, antibiotic management of non-perforated appendicitis was inferior to appendicectomy.

Quality Checklist for Randomized Clinical Trials:

Results: They recruited 936 patients from 11 children’s hospitals in Canada, the US, Finland, Sweden, and Singapore. 459 were assigned to the appendicectomy group and 477 were assigned to the antibiotic group.

Primary Outcome:

34% of the patients in the antibiotic group had treatment failure compared to 7% of the appendicectomy group. That was a difference of 26.7% (90%CI 22.4-30.9). Most treatment failure in the appendicectomy group was due to negative pathology.

In the antibiotic group, 72 (47%) met definition of treatment failure during the first admission.

Secondary Outcomes: 

Neither of the groups had deaths or serious adverse events.

The relative risk of having an adverse event related to the antibiotic treatment compared to the appendicectomy was 4.3 (95% CI 2.1-8.7). Most of these adverse events were classified as Gastrointestinal Distress.

Median length of stay was 1.0 day (IQR 0.76-1.68) for the appendicectomy group compared to 1.25 days (IQR 0.92-2.09) for the antibiotic group. The patients from the antibiotic group spent more time in the hospital during the 12 month follow up period 1.6 days (IQR 1.0-2.6) compared to 1.0 days (IQR 0.75-1.7).

The antibiotic group was able to return to normal activity and school faster than the appendicectomy group. They also did not require pain medications compared to the appendectomy Approximately three-quarters (73%) of the families surveyed from both groups reported being satisfied with their treatment.

Diagnosis of Appendicitis

In previous studies, the way a diagnosis of appendicitis is made has varied. Some studies have included imaging findings on CT scan or ultrasound. Some studies have included lab tests.

This study included patients with a diagnosis of simple, non-perforated appendicitis. They excluded those with suspicion of perforated appendicitis. How was this diagnosis made? We went back to the trial protocol on ClinicalTrials.gov to find some more details. It appears that all children with suspected acute non-perforated appendicitis were assessed by the on-call surgeon. The diagnosis could be made based on clinical suspicion with or without ultrasound imaging.

What is the gold standard for diagnosing appendicitis? We would imagine that surgical pathology consistent with the diagnosis is best but also recognize that is does not make any sense to remove the appendix of every child in the study.

Camille does not rely on imaging. However, often by the time she’s called to see the patient in ED, they’ve already had an ultrasound. Sometimes it’s helpful, sometimes it’s unnecessary, and sometimes it’s distracting. One of the common annoying scenarios is the finding of a mildly thickened 7mm appendix in a child who does have right inferior quadrant tenderness with no other signs of appendicitis, and parents are expecting an operation as the ultrasound says “appendicitis’ and the referring hospital has told them that’s why they were getting transferred. Many of these kids have a viral illness, causing lymphoid tissue in the wall of the appendix to hypertrophy, thereby enlarging the appendix.

Treat the patient, not the test or image finding.

Tests are an adjunct to clinical evaluation. They help us to confirm our diagnosis. How sure does a surgeon need to be to take a patient to theatre? How sure does an ED doctor need to be to call their surgeon to review? Seems like the threshold is different for different specialties, different hospitals, different practitioners, and different countries!

Selection Bias

Of the patients screened for eligibility in the study, 90% were excluded. Of those excluded, ~40% were excluded due to perforated appendicitis or suspected perforation, and the other 60% were excluded because they either declined to participate or “other reasons.”

Suspected perforation seems fairly subjective. I asked Camille to comment on how she clinically distinguishes between perforated or non-perforated appendicitis and the accuracy of making that determination based solely on physical exam.

The other group that was excluded were those who declined to participate or had other reasons. It would have been nice to know what those reasons were. A previous study found that a common reason parents declined to participate was they wanted to choose their treatment arm. Authors acknowledge this in the discussion section that they weren’t able to track the reasons for refusal or declined consents due to lack of funding.

Finally, another group that was excluded was pregnant patients, but pregnant people can get appendicitis too.

Appendicectomy Group vs. Antibiotic Group

There were two groups in this study, one group had surgery while the other received antibiotics. The patients in the antibiotic group received a minimum of 12 hours of IV antibiotics and were discharged if they were tolerating regular diet, pain was controlled, and vital signs were stable. If the patients in this group were not getting better, they could opt for another day of antibiotics or go for appendicectomy.  The surgical group was scheduled for appendicectomy in the next available slot. While these patients were waiting for the operating room, they also received IV antibiotics. The paper does not go into detail as to how long these patients who were in the surgery group waited. Previous research has demonstrated that it is fairly safe to delay surgery for appendicitis for 12 to 24 hours after presentation.

It is possible that these two group received similar treatment.  An antibiotic group  patient might have been on antibiotics for 1-2 days before changed over to getting an operation. An appendicectomy arm patient might be waiting 24-36 hours before getting their operation. Their study protocol specifies that the antibiotic group would have appendectomy by 48 hours if there was no clinical improvement. The surgery group would receive an appendectomy within 18 hours of randomization. We read both the paper and supplementary appendix to see if this actually occurred but couldn’t find any more information. And yes, a paper about appendicitis also has an appendix.

Additionally, the antibiotics given to patients may have varied. The authors write that the choice of antibiotic was dependent on the local centre. The variation in antibiotic regimen may also add some confounding but does help with generalizability. There is no consensus about the best antibiotic regimen for non-operative treatment of appendicitis.

Loss to Follow Up

The proportion of loss to follow up differed between the two groups. There was more data missing from the appendicectomy group compared to the antibiotic group (14% vs 5%). This may lead to attrition bias and over-estimate the treatment effect.

It is unclear why there was a higher proportion that were lost to follow up in the appendicectomy group. Is this because the patients who underwent appendicectomy did great and did not feel the need to follow up? Alternatively, did they not do as well? We don’t know.

Having more patients lost to follow up in the appendicectomy group may also lead to overestimating the difference in treatment failure between the two groups. The authors did perform a sensitivity analysis assuming event rates were the same in the missing data as the complete data without a change in their conclusions.

Non-inferiority Margin

The non-inferiority trial format is particularly relevant in this context, as it assesses whether antibiotic therapy is “not significantly worse” than surgery in terms of efficacy and safety.

This study had a proposed non-inferiority margin of 20%. This was decided as a compromise between patients and families and surgeons. Nonetheless, it is quite generous. Despite this margin that was set, this study still demonstrated that for appendicitis was inferior.

Different families and patients and surgeons probably have differing thresholds for how much risk of complications they are willing to tolerate.

The other question that we need to ask is what aspect of treatment is non-inferior? The primary outcome was treatment failure, but there were other aspects in the secondary outcomes that were also patient-oriented outcomes such as a faster return to school and activity, and less pain medication requirement in the antibiotic group. Those aspects may be more important to the family and patient. We saw very similar satisfaction rates between the two groups.

Although “appendicitis” is the one entity, it affects individuals in different ways, so that in patient-centered care, one size does not fit all.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusion but think there is more research to be done to investigate if there is a subset of low-risk patients who may do well with non-operative treatment.

Case Resolution: You and the surgical team engage in shared decision-making with the family and patient. You discuss the potential harms and benefits of operative versus non-operative management. The family expresses their desire to try and avoid surgery and the patient is admitted to the hospital for observation on IV antibiotics.

Clinical Application: 

Tune in to the podcast to hear how this paper changed or didn’t change Dr. Wu’s practice and her personal experience with non-operative treatment for appendicitis.

What do I tell my patient/family?

Thank you for your question. There have been many people studying whether we need to do surgery for appendicitis or if we can treat it with antibiotics. The results have been mixed. Let’s talk about the potential harms and benefits of each choice. If you decide that you want to try to avoid surgery, we can have your child stay in the hospital on IV antibiotics and observe him. If he gets better, we can send him home with oral antibiotics. If he gets worse or does not improve, we can revisit the discussion about performing surgery.

References

The post PODCAST: Cuts like a Knife or Antibiotics for Pediatric Appendicitis first appeared on האיגוד הישראלי לרפואה דחופה.

In this episode, we tackle the clinical mischief of Parvovirus B19, a common viral infection with a surprisingly wide range of manifestations—from the classic “slapped cheek” rash of erythema infectiosum to aplastic crises in children with hemolytic anemias and fetal hydrops in pregnant contacts. We’ll break down the virology, epidemiology, clinical presentation, and complications of Parvovirus B19. You’ll also learn how to manage exposures in the emergency department, especially when the child has a pregnant caregiver, and why isolation isn’t always necessary once the rash shows up.

Jordan, Jeanne A. “Treatment and Prevention of Parvovirus B19 Infection.” UpToDate, Jun. 14, 2024. https://www.uptodate.com/contents/treatment-and-prevention-of-parvovirus-b19-infection

Edwards, Morven S. “Clinical Manifestations and Diagnosis of Parvovirus B19 Infection.” UpToDate, Jun. 14, 2024. https://www.uptodate.com/contents/clinical-manifestations-and-diagnosis-of-parvovirus-b19-infection

Macri, Angela, and Crane, Jonathan S. “Parvoviruses.” StatPearls, NCBI Bookshelf, Jun. 28, 2023. https://www.ncbi.nlm.nih.gov/books/NBK482245/

Kostolansky, Sean, and Waymack, James R. “Erythema Infectiosum.” StatPearls, NCBI Bookshelf, Jul. 31, 2023. https://www.ncbi.nlm.nih.gov/books/NBK513309/

“Parvovirus B19 Infection and Pregnancy.” Centers for Disease Control and Prevention. https://www.cdc.gov/parvovirusb19/pregnancy.html

Note: This transcript was partially completed with the use of the Descript AI and the Chat GPT 4o AI

Welcome to PEMCurrents, the Pediatric Emergency Medicine Podcast. As always, I’m your host, Brad Sobolewski, and today we are covering Parvovirus B19—a common but clinically diverse viral infection that you will definitely encounter in pediatrics, and not just in the form of a rash. Parvovirus B19 is best known for causing fifth disease, but in certain patients it can lead to some serious complications like aplastic crises, fetal hydrops, or chronic anemia.

So as you can see, this virus does a lot of stuff. But what is it? Well, let’s get nerdy. It is a non-enveloped, single-stranded DNA virus in the Parvoviridae family. There are some forms of parvo that infect other mammals, but Parvovirus B19 is only for humans, and it loves erythroid progenitor cells. It was discovered by accident back in 1975, so a little bit before I was born, and it was labeled B19 because of the sample number in a Hepatitis B screening panel. Since then it has been identified as the cause of several syndromes. I’ll go over those as we move along here.

Parvovirus B19 is spread via respiratory droplets, much less commonly by blood products or vertical transmission. The incubation period is typically four to fourteen days. Viremia peaks at days five through ten after exposure, and that’s when the patient is most contagious. The classic rash and joint symptoms appear later, and at that point, the patient is actually no longer infectious. So that detail’s key—because when a kid shows up with a slapped cheeks rash, you no longer need to isolate them.

So the classic presentation that’s on every board exam ever is called erythema infectiosum, or fifth disease. This is the most well-known manifestation, seen primarily in school-aged children, especially in the spring and early summer. Again, it’s also known as fifth disease—this is one of the six classic childhood exanthems. These are a group of viral rash-causing illnesses that were originally numbered in the late 19th and early 20th centuries based on their order of description.

So: first disease was measles or rubeola, which obviously we don’t see as much anymore. Second disease was scarlet fever from group A Streptococcus. Third disease was rubella, or German measles. Fourth disease was Dukes’ disease, now believed to be a misclassified form of scarlet fever or staphylococcal scalded skin syndrome. Fifth disease is erythema infectiosum caused by Parvovirus B19. Sixth disease is roseola infantum, caused by HHV-6, and sometimes HHV-7.

Honestly, fifth disease is a historical happenstance—and I just think it’s fun to know that. Sometimes I share it with patients and families.

Here’s how it typically plays out. Phase one is the viral prodrome. This occurs during peak viremia. About 50% of symptomatic patients experience nonspecific flu-like symptoms: low-grade fever, malaise, myalgias, headache, coryza, nausea, and sometimes even diarrhea. This lasts about two to three days.

Phase two is the classic rash. This appears two to five days after the prodrome. You get an erythematous malar rash with circumoral pallor—the classic slapped cheeks appearance. You can also see a lacy, reticular rash on the trunk and extremities, which follows the slapped cheek rash about one to three days later. This rash can fade within a week or two, or it can wax and wane for weeks, especially worsening with sun, exercise, or stress. By the time the rash appears, viremia has resolved and the patient usually feels well.

Only about 25% of infected individuals will have this classic rash syndrome. Another 50% will only have mild flu-like illness, and 25% remain completely asymptomatic.

Let’s talk about the joint symptoms. These are seen in about one out of ten children. More commonly, adults—especially women—have joint symptoms, affecting up to 60% of them. Typically, joint symptoms are symmetric and affect the small joints of the hands, wrists, knees, and feet. The joint pains can last about one to three weeks. Chronic arthropathy occurs in a very small subset of patients and can last for months or more. Importantly, there’s no joint destruction—it hurts, but the joints are fine afterwards.

A serious manifestation of Parvovirus B19 infection that you do not want to miss is called transient aplastic crisis. This occurs when Parvovirus B19 halts erythropoiesis in patients with underlying hemolytic disorders like sickle cell disease, thalassemia, or hereditary spherocytosis. In one study of just over 300 patients with homozygous sickle cell disease, Parvovirus B19 infection caused transient aplastic crisis about 80% of the time.

Presenting symptoms are those of anemia: pallor, fatigue, tachycardia, weakness. You’ll often see a hemoglobin drop of greater than 30% from baseline, an undetectable reticulocyte count, and possibly leukopenia and thrombocytopenia. This often requires hospitalization and transfusion—in one series, 87% of children with transient aplastic crisis required packed red blood cell transfusions.

In immunocompromised children, B19 can also cause chronic infection, with persistent viremia and pure red cell aplasia. You’ll see this in transplant patients, patients with leukemia, or advanced HIV. These patients don’t get rash or joint symptoms—those are immune-mediated—and these kids have compromised immune systems. Diagnosis is confirmed with PCR, often as part of a viral panel, or via characteristic bone marrow findings. Treatment is with IVIG and, if possible, reduction of immunosuppression, though this can be tricky. These patients often need admission and careful care.

Let’s talk about fetal infection. Parvovirus B19 is not routinely screened for in pregnancy, but vertical transmission can cause hydrops fetalis, stillbirth, and severe fetal anemia. The risk is highest in the second trimester. The overall rate of fetal loss after maternal infection is around 2 to 6%, but it may be higher depending on timing and fetal response.

Now, let’s talk about a wonderfully named manifestation: papular purpuric gloves and socks syndrome. This is why pediatrics is great—we have the best names for things. This is a rare manifestation of Parvovirus B19, often seen in adolescents or young adults. You get painful, pruritic petechiae and purpura of the hands and feet, with a sharp demarcation at the wrists and ankles. You may also see mucosal erosions. You’re probably thinking, this sounds like mycoplasma or other viral illnesses—and it does. But unlike fifth disease, patients are contagious when this rash appears.

Finally, let’s talk about some rare neurologic complications. These include encephalitis, Guillain-Barré syndrome, and brachial plexopathy. One review identified about 129 cases of parvovirus-related neurologic complications between 1970 and 2012, with encephalitis making up about two-thirds of those cases. These are rare, but something to keep in mind—especially if you’re in a large academic children’s hospital.

So how do we diagnose Parvovirus B19? It’s usually a clinical diagnosis—especially in cases of typical erythema infectiosum. In more complicated cases or in immunocompromised children, you can check IgM antibodies (which appear about 7 to 10 days after exposure and peak at 2 to 3 weeks). IgG indicates past infection. PCR is most useful in immunocompromised patients or when evaluating possible fetal infection.

Management of erythema infectiosum is supportive care only—antipyretics, hydration, and reassurance. The rash can be itchy; use moisturizers or antihistamines like cetirizine. Explain to families that the rash may last for days to weeks and can worsen with sunlight. I’ve seen a lot of visits in urgent care where this is the main concern during outbreaks.

For joint symptoms, use NSAIDs. A patient with transient aplastic crisis will likely need hospitalization and red blood cell transfusion, especially if unstable. In immunosuppressed patients with chronic infection, treat with IVIG and carefully consider immunosuppressive management.

What if the child has a pregnant caregiver? The child is most contagious **before** the rash appears—during the viral prodrome—so it’s easy to mistake for another virus. Once the rash appears, the child is no longer infectious. If a pregnant household contact was exposed during the contagious period—especially in the first or second trimester—they should contact their OB provider for serologic testing (IgG and IgM). If seronegative, serial ultrasound may be recommended to monitor for fetal hydrops.

Isolation of the child is not necessary after the rash appears. If they are in the viremic phase, then hand hygiene and respiratory precautions are important to limit household spread.

Take-home points:

Thank you for listening to this episode. If you found it helpful, let me know. Leave a review, shoot me a message on social media or email, and share it with your colleagues and learners. And as my 13-year-old would like to remind me: like and subscribe.

For PEM Currents, this has been Brad Sobolewski. See you next time.

Brad Sobolewski, MD, MEd is a Professor of Pediatric Emergency Medicine and an Associate Director for the Pediatric Residency Training Program at Cincinnati Children’s Hospital Medical Center. He is on Twitter @PEMTweets and authors the Pediatric Emergency Medicine site PEMBlog and produces and hosts the PEM Currents: The Pediatric Emergency Medicine Podcast.

The post PODCAST: Parvovirus B19 (Fifth Disease) first appeared on האיגוד הישראלי לרפואה דחופה.

Reference: Ma K et al. A national survey of children’s experiences and needs when attending Canadian pediatric emergency departments. PLoS One. June 2024

Date: Oct 1, 2024

Guest Skeptic: Dr. Andrew (Andy) Tagg is an Emergency Physician with a special interest in education and lifelong learning. He is the co-founder of website lead of Don’t Forget the Bubbles (DFTB).

Dr. Andrew Tagg

Case: You are working with a medical trainee on her first clinical rotation through the emergency department (ED). One of the first patients she sees is a 12-year-old boy presenting with lower abdominal pain. He is accompanied by his worried parents. Before entering the room, she says to you, “This is the first time I’ve seen a pediatric patient. Do you have any tips for getting the history or performing the physical exam?”

Background: Through the course of one emergency department (ED) shift, we have countless interactions with patients from the initial history, examination, assessment, plan, updates on results from laboratory and imaging testing, reassessments, and eventually a final disposition. Working with children in the ED adds another layer of complexity as we are often trying to explain to them and their caregivers what is going to happen during their time in the ED.

Dr. Samina Ali

Children’s healthcare experiences can have a lasting impact on their understanding of health and their comfort in future medical settings.

For example, we discussed the importance of pain management with another Peds EM superstar, Dr. Samina Ali, on an SGEM Xtra and learned that poor pain management contributes to avoiding medical care in the future and even vaccine hesitancy.

While caregivers often advocate for their children, trying to understand the child’s needs and perspectives directly from the child is crucial for optimizing care.

Reference: Ma K et al. A national survey of children’s experiences and needs when attending Canadian pediatric emergency departments. PLoS One. June 2024

Authors’ Conclusions: “While almost all children felt well taken care of and were happy with their visit, close to 1/3 did not understand their diagnosis or its management. Children’s reported satisfaction in the ED should not be equated with understanding of their medical condition. Further, caution should be employed in using caregiver satisfaction as a proxy for children’s satisfaction with their ED visit, as caregiver satisfaction is highly linked to having their own needs being met.”

CROSS Quality Checklist for Survey Study

Results: They included 514 children and their caregivers. The mean age of children was around 12 years with 56.5% female. Mean age of caregivers was around 43 years and the majority (78%) were mothers. Most (87%) were discharged home and the rest were admitted or transferred.

The survey was split into four categories including: emotional, practical, and communication needs, and overall satisfaction with care.

Emotional: Close to 80% of children felt there was enough privacy during conversations with healthcare staff and during the examination. While this is not bad, it also means that 1 in 5 kids did not feel like their privacy was respected.

Communication: Over 90% of children said that the doctor or nurse spoke to them directly which is great. Unfortunately, only around 70% understood their diagnosis. Interestingly, more children (89%) reported understanding the rationale behind the tests that were done compared to their caregivers (78.5%).

Practical: The top three things to make kids happy were electronics, non-electronic entertainment (toys and crafts), and food and drinks. There were 40% who said nothing would make them more comfortable.

Overall: Most children (94.8%) were happy at the end of their ED visit. Is this because of the care received? Or just relieved that they were able to go home.

Biases

The participants were recruited via convenience sample over 1-week periods per season for four weeks total over a year. They were not able to recruit overnight. Recruitment was capped at 50 caregivers per seasonal week and 200 caregivers per site. The authors state this was for pragmatic and cost-related reasons. Were all those captured in this study necessarily reflective of the overall population seen in the emergency department?

Patients were recruited with all types of chief complaints. Most were deemed Urgent or Semi-Urgent Acuity on the Canadian Triage and Acuity Scale. It makes us wonder how responses to these questions may have changed in higher stress and higher-acuity situations.

Approximately 1 in 10 included in this study (12.9%) did not speak English at home. The study was limited to child-caregiver dyads who spoke English or French. There were practical considerations, but it is important to consider this as differences in language and culture may also impact the experiences.

In the United States, patients who are non-English speaking tend to be  under-triaged and non-white children tend to have longer wait times. [1,2]

Age Range

This study included a patient population over a wide age range (7 years to 17 years). 17-year-olds are not the same as 7-year-olds. We have to think hard about how we tailor our interaction and communication across this age spectrum. There’s a series from Wired called 5 Levels where they have an expert communicate a concept or topic at 5 different levels (child, teen, college student, etc.) at increasing complexity. This is a skill that we need to work on in medicine as our patients can vary in age and health literacy.

Their full survey did include a component to assess health literacy using a nutrition label for the caregivers, which was reported in a separate study. [3]

Talk Directly With Children

One easy thing to do for the age-appropriate child seems to be just talking directly with the kid. This was associated with a better understanding of treatment (OR 2.19) and decreased fear.

We’ve had experiences talking to children younger than seven where they can give a good history and answer questions. Sometimes parents also appreciate us talking directly with children because it’s a way for the kids to practice taking some responsibility for their health.

Community Involvement

Survey items were created with a literature review, team input, and parent advisory group review. They had a six-member expert panel that was multidisciplinary (emergency medicine, nursing, child life, parents, youth, and ED administrators). This resulted in a separate child survey in simpler language.

These patient and family partners can and should also be included as authors on the publication. We hope that this practice becomes more mainstream. It is an asset in studies to make sure we’re asking the right questions and looking at patient-oriented outcomes.

Patient Satisfaction Metric

This study demonstrates that patient satisfaction is an incomplete and imperfect metric. In this study over 90% of children felt well taken care of and were happy with their ED visit but only around 70% understood their diagnosis. Which one is more important? Despite many institutions emphasizing satisfaction or using Press Ganey scores, viewing it in isolation as a measurement of quality of care is inadequate. There are times when we should say “Sorry, antibiotics are not indicated for a cold or viral infection.” That’s better care although the patient may be disgruntled. We need to try and help them understand the clinical decision-making process.

Comment on Authors’ Conclusion Compared to SGEM Conclusion: We agree with the authors’ conclusion.

Case Resolution: You applaud the medical trainee for her awareness of the differing needs of children. You encourage her to introduce herself to the boy and family and sit during the examination. Because the boy is twelve years old, you encourage her to start by first engaging the boy and then asking the parents for any additional information. If there are any sensitive questions (sexual health), you encourage her to ask the parents to leave the room briefly to ask those questions directly to the patient.

Clinical Application: There are simple actions we can take to improve our clinical interactions. One basic thing we try to do is to sit when talking with our patients. [4,5] When seeing children in the emergency department, we encourage everyone to speak directly with the child if they are age-appropriate and respect their privacy when asking sensitive questions. Additional work needs to be done to determine best strategies for explaining diagnoses, testing, and treatment to children of various ages.

What Do I Tell My Student?

Thank you for asking that question. When seeing pediatric patients, we often can get history from the patient and the family. I try to start the conversation with the patient first and ask the family to fill in the parts that they might not know. This patient is presenting with lower abdominal pain. You may want to consider asking him some questions related to his sexual health. These questions are better asked in private, so it is appropriate to request the parents step out briefly. We also need to try and explain what we think is going on and what we’re going to do in language that the patient can understand.

References

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