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EVIDENCE BASED PEDIATRIC EMERGENCY MEDICINE:

ARE YOU PRACTICING IT?

Richard M. Cantor, MD FAAP/FACEPProfessor of Emergency Medicine and Pediatrics

Director of Pediatric Emergency ServicesDirector, Pediatric Emergency Medicine Fellowship

Medical Director, Central NY Poison Control CenterGolisano Children’s Hospital, Syracuse, NY

IS T

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TOPICS FOR TODAY

The Febrile Child/Meningitis

Respiratory Disorders

Fluids and Electrolytes

Surgical Problems

CryingAbuse and Neglect

New ProceduresParental presence

Pain management

THE FEBRILE CHILD

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ONCE UPON A TIME

• All infants less than 30 days with a temperature greater than 38C

received a full septic workup and admission

• Key concepts:

• You can’t trust these kids clinically

• Laboratory results may be unreliable

• The stakes are very high if you’re wrong

PREDICTING SEVERE BACTERIAL INFECTIONS IN WELL-APPEARING FEBRILE NEONATES:

LABORATORY MARKERS ACCURACY AND

DURATION OF FEVER

Pediatric Infect Dis J 2010;29: 227–232

Objectives

• To assess the diagnostic accuracy of

• WBC

• absolute neutrophil count (ANC)

• C-reactive protein (CRP)

• in detecting severe bacterial infections (SBI) in well-appearing

neonates with early onset fever without source (FWS)

• In relation to fever duration

Methods

• Observational study

• Previously healthy neonates 7 - 28 days of age, consecutively

hospitalized for FWS for less than 12 hours to a tertiary care Pediatric Emergency Department, over a 4-year period

• Laboratory markers were obtained upon admission in all patients

and repeated 6 to 12 hours after admission in those with normal

values on initial determination

Results

• 99 patients studied

• SBI documented in 25 (25.3%) neonates

• 62 patients presented had laboratory markers on initial determination

RESULTS

AROC Initially AROC at 12 Hours

CRP .78 .99

ANC .77 .85

WBC .59 .79

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Conclusions

• In well-appearing neonates with early onset FWS, laboratory

markers are more accurate and reliable predictors of SBI

when performed after > 12 hours of fever duration

• ANC and especially CRP resulted better markers than the

traditionally recommended WBC

Present Day Neonatal Fever

• Threshold temperature is 100.3

• ALL infants receive

• CBC

• Blood, urine and CSF cultures (including HSV)

• IV Cefotaxime and Ampicillin

• IV Acyclovir

• ALL are admitted

ONCE UPON A TIME

• All infants less than 3 months with a temperature greater than 38.5

received a full septic workup and admission

PREVALENCE OF OCCULT BACTEREMIA IN CHILDREN AGED 3 TO 36 MONTHS PRESENTING TO THE EMERGENCY DEPARTMENT WITH FEVER IN THE POSTPNEUMOCOCCAL CONJUGATE VACCINE

ERA

Academic Emergency Medicine 2009 16: 220–

225

Clinical Question

• What is the prevalence of occult bacteremia (OB) in well- appearing,

previously healthy children aged 3 to 36 months who present to the

emergency department (ED) with fever without source in the post–pneumococcal conjugate vaccine (PCV) era?

Methods

Children were included if they were

aged 3 to 36 months

febrilepreviously

healthy

had no source of

infection on examination

had a blood culture drawn

discharged from the ED

Retrospective study of children presenting to an urban PED over a 3 year period

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Results

ratio of 7.6 contaminants for each true-positiveratio of 7.6 contaminants for each true-positive

159 contaminant cultures - contaminant rate of 1.89%159 contaminant cultures - contaminant rate of 1.89%

21 true-positives, yielding an OB rate of 0.25% 21 true-positives, yielding an OB rate of 0.25%

8,408 children8,408 children

Conclusions

• Given the current rate of OB in the post-PCV era, it may no longer

be cost-effective to send blood cultures on well-appearing,

previously healthy children aged 3 to 36 months who have fever without source

BACTEREMIA IN CHILDREN 3 TO 36

MONTHS OLD AFTER INTRODUCTION OF CONJUGATED PNEUMOCOCCAL

VACCINES

PEDIATRICS Volume 139, number 4, April 2017

Methods

• Retrospective review of the electronic medical records of

all blood cultures collected on children 3 to 36 months

old at Kaiser Permanente Northern California

Results

• 57,733 blood cultures collected

• Implementation of routine immunization resulted in a

95.3% reduction of Streptococcus pneumoniae

bacteremia, decreasing from 74.5 to 3.5 per 100,000

children per year

• As pneumococcal rates decreased, Escherichia coli, Salmonella spp, and Staphylococcus aureus caused

77% of bacteremia

• Seventy-six percent of all bacteremia in the post-PCV13

period occurred with a source

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Conclusions

• In the United States, routine immunizations have made

bacteremia in the previously healthy toddler a rare event

• As the incidence of pneumococcal bacteremia has decreased, E coli, Salmonella spp, and S aureus have

increased in relative importance

• New guidelines are needed to approach the previously

healthy febrile toddler in the outpatient setting

ONCE UPON A TIME

• A positive NP aspirate for RSV in a febrile young infant <2 months

essentially rules out bacteremia/SBI

META-ANALYSIS TO DETERMINE RISK FOR SERIOUS BACTERIAL INFECTION IN FEBRILE

OUTPATIENT NEONATES WITH RSV INFECTION

Pediatr Emer Care 2016;32: 286–289

Objectives

Determine whether there is a clinically significant association between viral study results and risk for serious bacterial infection

Determine whether there is a clinically significant association between viral study results and risk for serious bacterial infection

Received sepsis evaluation and nasopharyngeal aspirate antigen testing (NPAT) for RSV infection

Received sepsis evaluation and nasopharyngeal aspirate antigen testing (NPAT) for RSV infection

Febrile neonates 28 days or youngerFebrile neonates 28 days or younger

Results

• Prevalence of + RSV in 387 febrile neonates was 6%

• 378 (98%) had both a sepsis evaluation and RSV NPAT

POSITIVE SBI

POSITIVE RSV 4/22 (18.1%)

NEGATIVE RSV 58/356 (16.2%)

Conclusions

Respiratory viral infection status is not an accurate clinical determinant in distinguishing SBI risk

in febrile neonates

Respiratory viral infection status is not an accurate clinical determinant in distinguishing SBI risk

in febrile neonates

Rates of + SBI are not significantly different between febrile neonates 28 days or younger with and without + RSVRates of + SBI are not significantly different between febrile neonates 28 days or younger with and without + RSV

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What’s On The Horizon?

• Association of RNA Biosignatures With Bacterial Infections in

Febrile Infants Aged 60 Days or Younger

• Diagnostic Test Accuracy of a 2-Transcript Host RNA Signature for Discriminating Bacterial vs Viral Infection in Febrile Children

MENINGITIS

ONCE UPON A TIME

• The clinician could rely on symptoms and signs for the

diagnosis of meningitis

• When performing a spinal tap, the infant should ““““kiss his

toes”””” in the fetal position

THE EFFECT OF BEDSIDE ULTRASONOGRAPHIC SKIN MARKING ON

INFANT LUMBAR PUNCTURE SUCCESS: A

RANDOMIZED CONTROLLED TRIAL

Ann Emerg Med. 2017;69:610-619

Methods

• Prospective, randomized, controlled trial in an academic

pediatric emergency department (ED)

• Infants younger than 6 months

• The conus medullaris and most appropriate intervertebral

space were identified and marked

• Subjects were considered to have a successful lumbar

puncture if cerebrospinal fluid was obtained and RBC counts

were less than 1,000/mm3

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Results

• 128 patients enrolled

• The first-attempt success rate was higher for the

ultrasonography arm (58%) versus the traditional arm (31%)

• Success within 3 attempts was also higher for the

ultrasonography arm (75%) versus the traditional arm

(44%)

Conclusion

• Ultrasonography-assisted site marking improved infant lumbar

puncture success in a tertiary care pediatric teaching hospital

• This method has the potential to reduce unnecessary hospitalizations and exposures to antibiotics in this vulnerable

population

POSITIONING FOR LUMBAR PUNCTURE IN CHILDREN EVALUATED BY BEDSIDE

ULTRASOUND

Pediatrics 2010; 125: e1149–e1153

Conclusions

• The interspinous space of the lumbar spine was maximally increased with children in the sitting position with flexed hips

• In the lateral recumbent position, neck flexion does not increase the interspinous space and may increase morbidity

FEBRILE CONVULSIONS

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ONCE UPON A TIME

• All children who suffered a febrile convulsion should receive a:

• Full septic workup

• An EEG

• A CT scan

• Probable admission

CLINICAL PRACTICE GUIDELINE—FEBRILE SEIZURES: GUIDELINE FOR THE NEURODIAGNOSTIC EVALUATION OF THE CHILD WITH A SIMPLE FEBRILE SEIZURE

PEDIATRICS Volume 127, Number 2, February

2011

Investigations

STUDIES

LP

EEG

LABS

CT/MRI

CONCLUSIONS

• Clinicians evaluating infants or young children after a simple

febrile seizure should direct their attention toward

identifying the cause of the child’’’’s fever

• Meningitis should be considered in the differential diagnosis

• For any infant between 6 and 12 months of age who presents

with a seizure and fever, a lumbar puncture is an option

when the child is considered deficient in Haemophilus

influenzae type b (Hib) or Streptococcus pneumoniae

immunizations

CONCLUSIONS

• A lumbar puncture is an option for children who are pretreated

with antibiotics

• In general, a simple febrile seizure does not usually require further evaluation, specifically electroencephalography,

blood studies, or neuroimaging

A WORD ABOUT……UTI’S

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DURATION OF FEVER AFFECTS

THE LIKELIHOOD OF A POSITIVE

BAG URINALYSIS OR CATHETER

CULTURE IN YOUNG CHILDREN

J Pediatr 2010;156:629-33

Study design

• Prospective study of 818 infants and children age 3-36 months with documented fever without source

• Following the documentation of fever from < 1 to > 5 days, bag specimens were collected for urinalysis

• The primary outcome was the yield of positive bag dipsticks by day, defined as positive for nitrates or more than trace leukocyte esterase

• The secondary outcome was positive catheter cultures on each day of fever

Results Conclusions

• The yield of positive bag urinalyses and catheter cultures

increased significantly in children with fever of 3 days or longer

duration

IT’S A FACT!

A NEW TECHNIQUE FOR FAST AND SAFE

COLLECTION OF URINE IN NEWBORNS

Arch Dis Child 2013; 98: 27-29

Design and methods

• A prospective feasibility and safety study conducted in the

neonatal unit of University Infanta Sofía Hospital, Madrid

• A new technique based on bladder and lumbar stimulation manoeuvres was tested over a period of 4 months in 80

admitted patients aged less than 30 days

• The main variable was the success rate in obtaining a

midstream urine sample within 5 min

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Results

• This technique was successful in 86.3% of infants

• Median time to sample collection was 45 s (IQR 30)

• No complications other than controlled crying were observed

UTI Present Day

• Recommended culture candidates

• Fever without source females under age 2

• Fever without source males under 6 months

• Fever without source uncircumcised males under 1 year

• Debatable worth in first 24 hours of fever

• Definitely more indicated after 3 days

• Remember a culture positive UTI in an child less than 2 years

is a PYELONEPHRITIS, not a simple cystitis

THE WORLD OF INFLAMMATORY MARKERS

ONCE UPON A TIME

• There was a smattering of ““““markers”””” used in evaluating the febrile child

• They were mostly surface antigens of the most common pathogens (S pneumo, H infl, N mening)

• Counterimmune electrophoresis (CIE) was performed on blood

OR urine OR CSF

• They were notoriously unreliable

A SCORE IDENTIFYING SERIOUS

BACTERIAL INFECTIONS IN CHILDREN WITH FEVER WITHOUT SOURCE

Pediatric Infectious Disease Journal • 27:654-656

2008

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PROCALCITONIN AND C-REACTIVE

PROTEIN AS DIAGNOSTIC MARKERS OF SEVERE BACTERIAL INFECTIONS IN

FEBRILE INFANTS AND CHILDREN IN

THE EMERGENCY DEPARTMENT

Pediatr Infect Dis J 2007; 26: 672-677

PROCALCITONIN TEST IN THE

DIAGNOSIS OF BACTEREMIA: A META-ANALYSIS

Ann Emerg Med. 2007;50:34-41

THE UTILITY OF SERUM C-REACTIVE

PROTEIN IN DIFFERENTIATING BACTERIAL FROM NONBACTERIAL

PNEUMONIA IN CHILDREN A META-

ANALYSIS OF 1230 CHILDREN

The Pediatric Infectious Disease Journal • 27,

2008

Inflammatory Marker Summary

• If all normal, most entities may be ruled out

• Septic arthritis

• Osteomyelitis

• Inflammatory Bowel disease

• Appendicitis (maybe)

• Every other result is debatable

CROUP

ONCE UPON A TIME

• ALL infants with croup received mist therapy

• ALL infants with croup who received Vaponephrine

necessitated admission (fear of “rebound”)

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CONTROLLED DELIVERY OF HIGH VS LOW

HUMIDITY VS MIST THERAPY FOR CROUP IN

EMERGENCY DEPARTMENTS

JAMA 2006 295:1274-1280

HIGH VS LOW HUMIDITY VS MIST

THERAPY

• To determine whether a significant difference in the clinical

Westley croup score exists in children with moderate to severe

croup who were admitted to the emergency department and who received either

• 100% humidity

• 40% humidity via nebulizer

• blow-by humidity

HIGH VS LOW HUMIDITY VS MIST

THERAPY

• 100% humidity with particles specifically sized to deposit

in the larynx failed to result in greater improvement

than 40% humidity or humidity by blow-by technique

• This study does not support the use of humidity for

moderate croup for patients treated in the emergency

department

VAPONEPHRINE IN CROUP

• Recent reviews suggest that it is safe to discharge a

child who has received nebulized epinephrine for croup

after 2 to 3 hours of observation if the child has

• No stridor at rest

• Normal air entry

• Normal color

• Normal level of consciousness

• Received one dose of 0.6 mg/kg dexamethasone

orally or intramuscularly

Peds in Review 2001:22:5

KAWASAKI DISEASE

ONCE UPON A TIME

• To make the diagnosis of Kawasaki Disease, most of the

following should be present:

• Fever for 5 days

• Irritability

• Conjunctival involvement

• Oral changes

• Lymphadenopathy

• Erythroderma

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CHARACTERISTICS OF KAWASAKI DISEASE IN INFANTS

LESS THAN 6 MONTHS OF AGE

Study Question/Methods

• What are the characteristics of KD in infants < 6 months?

• 120 patients with Kawasaki disease

• Group 1 = 20 (17%) patients < 6 mos

• Group 2 = 100 (83%) patients > 6 mos

Age Related Differences in KD

Over 6 Months Under 6 Months

WBC 21,740 11,830

Platelets 483 355

Triglycerides 138 107

Hydrops 0% 16%

RESULTS

• Younger infants more likely to have

• incomplete presentation (35% vs 12%)

• coronary involvement (65% vs 19%)

• late intravenous immunoglobulin treatment

• relatively poor outcome

CONCLUSIONS

• Infants younger than 6 months with prolonged unexplained

febrile illnesses

• suspect Kawasaki disease (despite incomplete clinical

presentation)

• Echocardiogram an important implement for diagnosis

• Early IVIG required

TREATMENT OF VIRAL

GASTROENTERITIS

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ONCE UPON A TIME

• Antiemetics were contraindicated in the treatment of viral

gastroenteritis

• Compazine

• Phenergan

• Atropine

THEN ALONG CAME ONDANSETRON

UTILIZATION OF ONDANSETRON IN THE

PEDIATRIC EMERGENCY DEPARTMENT:

BEYOND ACUTE GASTROENTERITIS

Annals of EM 2010 56: S100

Results

• During the study period, 32,971 patients received ondansetron

in the PED, 12,620 (38%) were non-GE patients

• The non-GE patients

• older (8.3 years versus 4.3 years, p < 0.001)

• had a higher average initial triage level

• 79% received ondansetron enterally

• 71% were discharged home

• 37% of the discharged patients received a prescription for ondansetron

Results

Discharge Diagnosis

fever (15%)

abdominal pain/tenderne

ss (13%)

head injury/concus

sion (7%)

pharyngitis(6%)

viral infection (6%)

migraine variants (5%)

otitis media (5%)

RESULTS

Admission Diagnosis

appendicitis (11%)

asthma (6%)

pneumonia (4%)

diabetes (4%)

DON’T FORGET THE ULTIMATE ANTIEMETIC

Positive Cheetos Sign

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PYLORIC

STENOSIS/APPENDICITIS

ONCE UPON A TIME

• All infants with pyloric stenosis

• Had classic signs

• Had metabolic alkalosis

• Necessitated a barium swallow

• All cases of suspected appendicitis had

• Fever

• Anorexia

• Psoas sign

• Elevated WBC

THE CHANGING CLINICAL PRESENTATION OF HYPERTROPHIC PYLORIC STENOSIS: THE EXPERIENCE OF A LARGE, TERTIARY CARE

PEDIATRIC HOSPITAL

Clinical Pediatrics 50(3) 192 –195 2011

STUDY CONCLUSIONS

• Reviewed the clinical and laboratory data from cases of

hypertrophic pyloric stenosis (HPS) diagnosed at their

institution from 2006 – 2008

• A total of 118 patients were included in this study

• An ““““olive”””” was palpated in only 13.6% of cases

STUDY CONCLUSIONS

• This is in contrast to older studies, where more than 50% of the

patients were reported to have a palpable “olive” depending on

when the study was conducted

• In patients from this institution, hypochloremia was present

in 23% and alkalosis in 14.4%, which are less frequent than

the incidence of these abnormalities in older studies

• The reason for this change appears to be the frequent use of

ultrasound

ATYPICAL CLINICAL FEATURES OF PEDIATRIC APPENDICITIS

Academic Emergency Medicine 2007; 14:124–

129

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Atypical Clinical Features of Pediatric

Appendicitis

• Among patients with appendicitis, most common atypical

features

• absence of pyrexia (83%)

• absence of Rovsing’s sign (68%)

• absence of rebound pain (52%)

• lack of migration of pain (50%)

• lack of guarding (47%)

• abrupt onset of pain (45%)

• lack of anorexia (40%)

• absence of maximal pain in the right lower quadrant (32%)

• absence of percussive tenderness (31%)

ALTE

ONCE UPON A TIME

• Patients with suspected ALTE necessitated admission for

observation only

• If they appeared well, no workup was needed in the PEDBRIEF RESOLVED UNEXPLAINED EVENTS (FORMERLY APPARENT LIFE-THREATENING EVENTS) AND EVALUATION OF LOWER-RISK INFANTS

PEDIATRICS Volume 137, number 5, May

2016:e20160590

What The Heck Is A BRUE?

Definition

The term BRUE is defined as an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of

≥1 of the following

The term BRUE is defined as an event occurring in an infant younger than 1 year when the observer reports a sudden, brief, and now resolved episode of

≥1 of the following

(1) cyanosis or pallor

(2) absent, decreased, or irregular breathing

(3) marked change in tone (hyper- or hypotonia)

(4) altered level of

responsiveness

Definition

By using this definition and framework, infants younger than 1 year who present with a BRUE are categorized

either as

By using this definition and framework, infants younger than 1 year who present with a BRUE are categorized

either as

(1) a lower-risk patient on the basis of history and physical

examination for whom evidence-based recommendations for

evaluation and management are offered

(2) a higher-risk patient whose history and physical examination suggest the need for further investigation and treatment but for whom recommendations are

not offered

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APPARENT LIFE-THREATENING EVENT ADMISSIONS AND GASTROESOPHAGEAL REFLUX DISEASE: THE VALUE OF

HOSPITALIZATION

Pediatr Emer Care 2012;28: 17Y21

DISCHARGE DIAGNOSIS

CONCLUSIONS

• Concordance of initial working diagnosis with discharge

diagnosis of GERD in ALTE patients is high

• However, in hospital events, evolution to new diagnoses and recurrent ALTE suggest that hospitalization of these patients

is beneficial

• Diagnostic studies should not be routine but should target

concerns from the history, examination, and hospital course

ACCIDENTAL AND NONACCIDENTALPOISONINGS AS A CAUSE OF

APPARENT LIFE - THREATENING EVENTS IN INFANTS

Pediatrics 2008 122: e359-e362

Results

596 children presented with an ALTE

46.0% had a toxicology screen performed

50 truly positive (18.2%), 23 positive screen results were considered clinically significant (23 of 274 [8.4%])

13 toxicology screen results were positive for an over-the-counter cold preparation (13 of 274)

No parent admitted to having given his or her child an over-the-counter cold preparation

Conclusions

• A substantial number of children presenting to the emergency

department with an ALTE had a positive toxicology screen

result

• In particular, a number of children were found to have been

given an over-the-counter cold preparation

• Recommend that toxicology screens be included as part of

the routine evaluation of children who present with an apparent

life-threatening event

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THE CRYING CHILD

THE CRYING INFANT: DIAGNOSTIC

TESTING AND FREQUENCY OF SERIOUS UNDERLYING DISEASE

Pediatrics 2009 123: 841-848

Results

However, only 8 (1.4%) diagnoses were assigned on the basis of a positive investigation

Of the 574 tests performed, 81 (14.1%) were positive

12 (5.1%) children had serious underlying etiologies with urinary tract infections being most prevalent (n =3)

237 patients

Results

Both of these children were < 4 months of age and had urinary tract infections

In only 2 (0.8%) children did investigations in the absence of a suggestive clinical picture contribute to the diagnosis

Unwell appearance was associated with serious etiologies

History and/or examination suggested an etiology in 66.3% of cases

Results

Successful follow-up was completed with 60% of caregivers, and no missed diagnoses were found

Ocular fluorescein staining and rectal examination with occult blood testing were performed infrequently, and results were negative in all

cases

Among children <1 month of age, the positive rate of urine cultures performed was 10%

Conclusions

• History and physical examination remains the cornerstone of

the evaluation of the crying infant and should drive

investigation selection

• Afebrile infants in the first few months of life should undergo

urine evaluation

• Other investigations should be performed on the basis of

clinical findings

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A WORD ABOUT HEAD INJURIES

A QUICK AND DIRTY BATTLE

YOU NEED TO WIN

The Child With a CHI Referred for a CT Scan

Regardless of what you tell them, THEY WANT A CT SCAN

Regardless of what you tell them, THEY WANT A CT SCAN

Your Hx and PE take all of 10 minutesYour Hx and PE take all of 10 minutes

The children (and parents) are tired and hungryThe children (and parents) are tired and hungry

These kids always arrive at the busiest timesThese kids always arrive at the busiest times

The Child With a CHI Referred for a CT Scan

• What to say to these parents

• There have been large multicenter studies which

provide guidelines for the evaluation of CHI in infants and children

• This child does NOT meet criteria for a CT Scan

• Radiation is harmful

• The child will more than likely grow up to necessitate CT scanning in the future

• You will probably have to sedate the child to do the

study

If All Else Fails, And They Demand An MRI…..

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CHILD ABUSE

ONCE UPON A TIME

• The ED work up of suspected abuse

• Careful PE

• Photographs

• Indepth interviews

• Optional items

• Lab work

• CT scanning

• Skeletal survey

ILLICIT DRUG EXPOSURE IN PATIENTS

EVALUATED FOR ALLEGED CHILD ABUSE

AND NEGLECT

Pediatr Emer Care 2011;27: 490Y495

USE OF SKELETAL SURVEYS TO EVALUATE

FOR PHYSICAL ABUSE: ANALYSIS OF 703

CONSECUTIVE SKELETAL SURVEYS

Pediatrics 2011; 127: e47–e52

FOREIGN BODY INGESTIONS

ONCE UPON A TIME

• All ingested foreign bodies

• If below the cricothyroid level

• Observation at home

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EMERGING BATTERY-INGESTION

HAZARD: CLINICAL IMPLICATIONS

Pediatrics 2010;125:1168–1177

COOL NEW SIGNS AND

PROCEDURES

THE RED UMBILICUS: A DIAGNOSTIC

SIGN OF COW’S MILK PROTEIN INTOLERANCE

JPGN 42:531-534, 2006

Red Umbilicus

NASAL FOREIGN BODY

REMOVAL IN CHILDREN

Pediatric Emergency Care 24: 785 2008

Foley Extractor Technique

Bypass Obstruction Inflate Balloon

Withdraw

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RANDOMIZED COMPARISON OF

PAIN PERCEPTION DURING RADIAL

HEAD SUBLUXATION REDUCTION

USING SUPINATION-FLEXION OR

FORCED PRONATION

Daniel A. Green, MD

Pediatric Emergency Care 2006 22: 235-238

OLD School NEW School

THE ANATOMIC RELATIONSHIP OF FEMORAL VEIN TO FEMORAL ARTERY IN EUVOLEMIC PEDIATRIC PATIENTS BY ULTRASONOGRAPHY: IMPLICATIONS

FOR PEDIATRIC FEMORAL CENTRAL VENOUS ACCESS

Academic Emergency Medicine 2008; 15:426-430

Femoral Vein

CHANGING PHILOSOPHIES

YOUNG CHILDREN’S PERCEPTIONS OF

PHYSICIANS WEARING STANDARD

PRECAUTIONS VERSUS CUSTOMARY ATTIRE

Pediatric Emergency Care 2006 22:13-17

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ChoicesPARENT PRESENCE DURING COMPLEX

INVASIVE PROCEDURES AND CARDIOPULMONARY RESUSCITATION:

A SYSTEMATIC REVIEW OF THE

LITERATURE

Pediatrics 2007;120;842-854

Evidence Yield (key words)

Search Terms Results, n

Pediatric resuscitation 93

Pediatric codes 3

Pediatric and CPR 373

Family presence and resuscitation 66

Parental presence and resuscitation 7

Parent presence and resuscitation 1

Parental presence and invasive procedures

7

Parent presence and invasive procedures

1

Family-witnessed resuscitation 8

Medical-legal and pediatrics 27

CHILD LIFE SERVICES

AAP POLICY

• Child life services should be considered an essential

component of quality pediatric health care and are

integral to family-centered care and best-practice models of health care delivery for children

• Child life services should be provided directly by or in

consultation with qualified child life specialists in pediatric inpatient units, ambulatory areas, emergency

departments, and chronic care centers to the extent

appropriate for the population served

PUTTING AN END TO

PEDIATRIC PAINFUL PROCEDURES

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THE GOAL: “PAINLESS” PEDIATRIC

EMERGENCY MEDICINE

68 references

THANKS!