Tweaks (of the Twade) in Pediatric Emergency Medicine

April 2006

Laurie J. Burton, MD

ASTHMA

ASTHMA

Pulses paradoxus is a fairly good measure of degree of obstruction. “> 12-14” indicates “severe”

Automatic device to measure PP, not requiring cooperative child

Steroids work as anti-inflammatory agents but also add more beta receptors for albuterol, even in the 1st 1-2 hours

“10 minute difference” of iv versus oral steroids

ASTHMA

Noncompliant or vomiting patients- consider dexamethasone 0.6mg/kg x 1

Magnesium dosing at other institutions is 50-75mg/kg iv over 20 minutes, a little higher than our 40mg/kg iv

BRONCHIOLITIS

BRONCHIOLITIS

What about the newborns ie < 3 month olds with bronchiolitis? Who do you test? Who do you admit?

CHOA bronchiolitis guidelines remove those < 1 month from pathway

Cincinnati Children’s guidelines state, “healthy infants with bronchiolitis < 3 mo are at particular risk for hospitalization”

Bronchiolitis

88% apnea occurs in the 1st 48 hours, Kneyber 1998

PEM listserv…? admit all RSV+ or clinical bronchiolitis

under 4 weeks of age who present within 1st 48 hours

? admit all RSV + infants with significant risk factors eg chronic lung, congenital heart

Bronchiolitis

Natural course:? Usually past the worst at day 5 (unless

complication)18% still symptomatic at 3 weeks

Bronchiolitis

PEM listserv con’t? admit all RSV + infants < 3 mo within 1st

72 hours? Admit all infants < 3 mo with wheezing,

retractions or tachypnea by history or exam in 1st 72 hours

Bronchiolitis

PEM listserv con’t… ? No routine testing of infants < 3 mo without

history of apnea or lower tract signs or symptoms

Recent study showing po dexamethasone may decrease hospitalization at 4 h (44% vs 19%)

Current multicenter trial (including CHOA) which may answer some of these questions

ECGS/ CARDIO

ECGS / CARDIOLOGY

all emergency department ECGs should be reviewed by a pediatric cardiologist

One study showed 11/16 ECGs thought minor by PEM were major by Peds Cardio

24/94 thought no F/U needed by PEM thought F/U needed by Peds Cardio

ECGs / Cardiology

Cyanotic newborn:Trick to remember the 5 T’s1 = truncus (1 trunk)2 = transposition of the 2 great arteries3 = TRIcuspid atresia4 = TETRAlogy of Fallot5 = Total anomalous pulm venous returnNOTE: all have normal ECG except #3

ECGs / Cardiology

EVIDENCE BASED MEDICINE

Evidence Based Medicine

Definition:There is a management question, and in

this decision goes the following… High quality evidence MD experience Patient & MD preference Pathophysiologic reasoning

Evidence Based Medicine

Some great websites (free)

http://researchinpem.homestead.com

/homepage/htmlhttp://www.cochrane.org/reviewshttp://www.bestbets.orghttp://www.guideline.gov

TYLENOL OVERDOSE

Tylenol overdose

Nomogram based on tylenol with a narcotic (eg T3, Percocet, Vicodyn), delayed gastric emptying

Loading dose of 20mg/kg po plain tylenol is perfectly safe

Peak for plain tylenol ingestion probably 2 hours, not 4 hours

NAC can be used even beyond 48 hours

MEDICOLEGAL ISSUES

Medico legal issues in PEM

27% pediatricians named in suit43% PEMs named in suitOf the suits,

33% dropped 36% settled 19% in progress 12% to trial….

• 75% MD wins, 25% plaintiff wins

Medico legal issues in PEM

#1 type of suit = failure to diagnoseTOP CAUSES:

Appendicitis, meningitis, myocarditis Wounds & lacerations, dehydration SCFE, testicular torsion

Medico legal issues in PEM

High risk patients: Previous visit same problem Multiple caregivers Inconsolable child Fever and abdominal pain

Medico legal issues in PEM

Marc Gorelick, “Never say ‘just’ and ‘virus’ in the same sentence.”

No false reassurances

Medico legal issues in PEM

MD pitfalls: Not reading RNs notes, EMS reports, resident’s

notes Ignoring abnormal vital signs Trusting the residents Not listening to the nurses

Remember, “just sit down” campaign- never act rushed

REHYDRATION / ZOFRAN

Rehydration/ Zofran

Clinically we overestimate the level of dehydration. -Lancet study

WHO criteria: Oral rehydration:

irritable, sunken, no tears, dry mm, slow turgor IV rehydration:

lethargic/floppy, very sunken, no tears, very dry mm, unable to drink

Rehydration/ Zofran

CONTRAINDICATIONS to oral rehydration: Cardiovascular instability Surgical abdomen Na > 160 meq/L Parental fatigue

Rehydration/ Zofran

Oral rehydration solutions have Na 80meq/L but taste is unacceptable

Pedialyte maintenance solutions have Na 50meq/L

Gatorade sports solutions have lower Na and higher glucose

Rehydration/ Zofran

Academic calculation of oral rehydration amount: 50ml/kg over 4-6 hours Add maintenance (same as iv calculation) Add losses

5-10ml/kg for each diarrheal stool 2-3ml/kg for each emesis

Rehydration/ Zofran

What a lot of ED folks do…

5-10ml every 2-5 minutes, 15-30 minute initial trial

Rehydration/ Zofran

Reasonable recommendations for Zofran… Not dehydrated => don’t use Not straightforward diagnosis => don’t use < 6 months => don’t use (less clear if AGE)

AAP publication recommendation

Rehydration/ Zofran

Zofran prescriptions (Anecdotal info)Example- 4mg ODT, dispense 2

Private insurance co-pay $15 Medicaid covers, no charge One pharmacy did not feel comfortable filling in

an 8 month old, “too young” CVS charges $54.59 self pay HSCH patient said the 8mg was going to cost

“Four hundred dollars” ????

PAIN / SEDATION

Pain / Sedation

Reminder that 1 procedure with poor control of pain => memory can last a lifetime

Particularly important in “naïve” child who will be undergoing multiple painful procedures in the future eg newly diagnosed leukemic etc

Pain / Sedation

Routine use of po Versed as anxiolytic (not conscious sedation) of children < 4 yo with lacerations, especially to the face

WOUNDS

Wounds

Case 1 –

12 yo laceration to forearm 15cm x 3cm

Weight is 30 kg

Would you use LET?

How much is your maximum dose of lidocaine with epi you can use if you use LET?

Wounds

Using LET is often worthwhile on extremities

If you use LET, then use no more than 5mg/kg lidocaine with epinephrine by injection One article’s recommendation

Wounds

NO STERI-STRIPS WITH DERMABOND- The child may pick off the strips and the

dermabond may come off with it

NO BATHING AND SWIMMING WITH DERMABOND Shower is fine

Wounds

Suture kits at HSCH and EG have 27G & 25G needle, much less painful with 27G

Slow injection of lidocaineBicarb buffer

Wounds

Remember railroad tracks on face –

TRICK: if use Fast Absorbing Gut & sutures still present > 5 days, have them rub with soapy water and will break sutures

Wounds

Bites: No dermabond Dog bites: usually < 20% infection rate, Cat bites usually < 80% Pasturella in about 80% of cat bites- CLINDA does not cover Pasturella. Augmentin,

cefuroxime, and azithromycin dosRabid cats now outnumber rabid dogs

Wounds

Case 2

Wounds

Wounds

This is what happened….

THE END