Tweaks (of the Twade) in Pediatric Emergency Medicine

1. Tweaks (of the Twade) in Pediatric Emergency Medicine April 2006 Laurie J. Burton, MD

2. ASTHMA

3. 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

4. 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

5. BRONCHIOLITIS

6. 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”

7. 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

8. Bronchiolitis • Natural course: • ? Usually past the worst at day 5 (unless complication) • 18% still symptomatic at 3 weeks

9. 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

10. 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

11. ECGS/ CARDIO

12. 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

13. ECGs / Cardiology • Cyanotic newborn: • Trick to remember the 5 T’s • 1 = truncus (1 trunk) • 2 = transposition of the 2 great arteries • 3 = TRIcuspid atresia • 4 = TETRAlogy of Fallot • 5 = Total anomalous pulm venous return • NOTE: all have normal ECG except #3

14. ECGs / Cardiology

15. EVIDENCE BASED MEDICINE

16. 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

17. Evidence Based Medicine • Some great websites (free) • http://researchinpem.homestead.com /homepage/html • http://www.cochrane.org/reviews • http://www.bestbets.org • http://www.guideline.gov

18. TYLENOL OVERDOSE

19. 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

20. MEDICOLEGAL ISSUES

21. Medico legal issues in PEM • 27% pediatricians named in suit • 43% PEMs named in suit • Of the suits, • 33% dropped • 36% settled • 19% in progress • 12% to trial…. • 75% MD wins, 25% plaintiff wins

22. Medico legal issues in PEM • #1 type of suit = failure to diagnose • TOP CAUSES: • Appendicitis, meningitis, myocarditis • Wounds & lacerations, dehydration • SCFE, testicular torsion

23. Medico legal issues in PEM • High risk patients: • Previous visit same problem • Multiple caregivers • Inconsolable child • Fever and abdominal pain

24. Medico legal issues in PEM • Marc Gorelick, “Never say ‘just’ and ‘virus’ in the same sentence.” • No false reassurances

25. 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

26. REHYDRATION / ZOFRAN

27. 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

28. Rehydration/ Zofran • CONTRAINDICATIONS to oral rehydration: • Cardiovascular instability • Surgical abdomen • Na > 160 meq/L • Parental fatigue

29. 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

30. 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

31. Rehydration/ Zofran • What a lot of ED folks do… • 5-10ml every 2-5 minutes, 15-30 minute initial trial

32. 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

33. 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” ????

34. PAIN / SEDATION

35. 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

36. Pain / Sedation • Routine use of po Versed as anxiolytic (not conscious sedation) of children < 4 yo with lacerations, especially to the face

37. WOUNDS

38. 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?

39. 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

40. 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

41. Wounds • Suture kits at HSCH and EG have 27G & 25G needle, much less painful with 27G • Slow injection of lidocaine • Bicarb buffer

42. 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

43. 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 dos • Rabid cats now outnumber rabid dogs

44. Wounds • Case 2

45. Wounds

46. Wounds • This is what happened….

47. THE END