The EP additionally cannot undervalue the importance of trending vital signs and should never assume that tachycardia and tachypnea are due to crying alone. The onus is on the EP to consider and exclude serious illness, and nonemergent causes of prolonged crying should not be diagnosed in the setting of lethargy or poor feeding without a thorough workup. Any infant who is crying too much and eating too little per parental history is an infant who should be screened for possible underlying serious disease.
Case Conclusion
The patient in this case was found to be afebrile, tachycardic, tachypneic, and with a normal oxygen saturation while crying inconsolably on initial examination. Upon removal of the infant’s closed-footed pajamas, the distal second toe of his right foot was noted to be markedly swollen and erythematous. The EP recognized the presence of a hair tourniquet but was unable to unwind the constricting hair due to the small size of the infant’s toe and extent of tissue swelling. Topical anesthetic cream was first applied to the toe and, as there was no visible laceration of the skin, depilatory cream was subsequently applied to the tourniquet. After 10 minutes, the toe was rubbed and rinsed with water and the hair tourniquet dissolved. There was significant improvement in tissue swelling and color within 1 hour of removal of the constricting band. The affected toe demonstrated adequate capillary refill and no sign of persistent vascular compromise. The patient’s crying subsided and his vital signs and remainder of his physical examination were normal.
Since there was evidence of superficial skin breakdown at the site of the hair tourniquet, the patient’s father was instructed to apply topical antibiotic ointment to the site and to follow-up with the patient’s pediatrician in 24 hours. Of note, the father stated that the infant’s mother had been experiencing significant postpartum hair loss recently and that they would now be careful to remove loose hair from the baby’s clothing and bedding—especially when dressing him in closed-footed pajamas or mittens.
Dr Leader is a fellow, department of pediatric emergency medicine, Eastern Virginia Medical School, Norfolk, Virginia. Dr Clingenpeel is a fellowship director, pediatric emergency medicine, and associate professor of pediatrics, Eastern Virginia Medical School, Norfolk.