best of the best in pediatrics - chairman's welcome ... · best of the best in pediatrics...
TRANSCRIPT
Best of the Best in
Pediatrics
Recent Articles Yoursquove Got
to Know
Mimi Lu MD FAAEM Clinical Assistant Professor
Assistant Residency Program Director
Director Pediatric Emergency Medicine Education
University of Maryland School of Medicine
Baltimore Maryland
No relevant financial disclosures
Mimi Lu MD FAAEM Clinical Assistant Professor
Assistant Residency Program Director
Director Pediatric Emergency Medicine Education
University of Maryland School of Medicine
Baltimore Maryland
Outline Recent literature pertaining to
Seizures
Trauma
Bronchiolitis and asthma
Questions mluumarylandedu
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 2 minutes
Simple Complex
Febrile Seizures
6 months to 5 years
Generalized
Lasts lt 15 min
No recurrence
within 24 hours
Focal
Duration gt 15 min
Recurrence within
24 hours
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 2 minutes
0
2011 AAP Guidelines
Only for simple febrile seizures
SIMPLE If well-appearing normal neuro exam return to baseline
NO NEED FOR INVASIVE TESTING
COMPLEX
Less Clear
More concerning for underlying pathology
If well-appearing more conservative approach of little
benefit
Workup for complex febrile seizure
Imaging
Kimia et al Pediatr Emerg Care 2012
Diagnostic studies
Hardasmalani and Saber Pediatr Emerg Care 2012
Lumbar puncture
Fletcher and Sharieff West J Emerg Med 2013
First complex febrile seizure
Conclusion(s)
Emergent neuroimaging and extensive
diagnostic studies including LP may be
unnecessary for well-appearing children
without other signs or symptoms
Recurrent brief nonfocal seizure
particularly low risk for positive findings
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 15 min
Given medication
Which agent
Randomized control trial
IN midazolam vs IV diazepam
50 patients
1 month to 12 years
Seizure gt10 minutes
Which agent
Midazolam (IN)
Faster time to medication initiation
Shorter time hospital arrival to seizure control
Diazepam (IV)
Decrease interval from drug to seizure control
Conclusion
IN midazolam is as effective as IV diazepam for treatment of acute seizures in children
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 40 min
Given medication(s)
copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2
Continuum of seizures
Abend et al PEC 2008
Febrile status epilepticus (FEBSTAT)
Seinfeld et al Epilepsia 2014
Total duration depends on
Time to AED initiation
Time from AED to seizure termination
Early intervention = shorter duration
Status epilepticus first line
Benzos
Benzos
Benzos
Status epilepticus second line
Yasiry and Shorvon Seizure 2014
Meta-analysis evaluating efficacy of 5 AED
in convulsive benzodiazepine-resistant
status epilepticus
Conclusion
Valproate levetiracetam and
phenobarbital first line after benzos
Evidence did not support phenytoin as
first line or routine lacosamide
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
No relevant financial disclosures
Mimi Lu MD FAAEM Clinical Assistant Professor
Assistant Residency Program Director
Director Pediatric Emergency Medicine Education
University of Maryland School of Medicine
Baltimore Maryland
Outline Recent literature pertaining to
Seizures
Trauma
Bronchiolitis and asthma
Questions mluumarylandedu
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 2 minutes
Simple Complex
Febrile Seizures
6 months to 5 years
Generalized
Lasts lt 15 min
No recurrence
within 24 hours
Focal
Duration gt 15 min
Recurrence within
24 hours
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 2 minutes
0
2011 AAP Guidelines
Only for simple febrile seizures
SIMPLE If well-appearing normal neuro exam return to baseline
NO NEED FOR INVASIVE TESTING
COMPLEX
Less Clear
More concerning for underlying pathology
If well-appearing more conservative approach of little
benefit
Workup for complex febrile seizure
Imaging
Kimia et al Pediatr Emerg Care 2012
Diagnostic studies
Hardasmalani and Saber Pediatr Emerg Care 2012
Lumbar puncture
Fletcher and Sharieff West J Emerg Med 2013
First complex febrile seizure
Conclusion(s)
Emergent neuroimaging and extensive
diagnostic studies including LP may be
unnecessary for well-appearing children
without other signs or symptoms
Recurrent brief nonfocal seizure
particularly low risk for positive findings
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 15 min
Given medication
Which agent
Randomized control trial
IN midazolam vs IV diazepam
50 patients
1 month to 12 years
Seizure gt10 minutes
Which agent
Midazolam (IN)
Faster time to medication initiation
Shorter time hospital arrival to seizure control
Diazepam (IV)
Decrease interval from drug to seizure control
Conclusion
IN midazolam is as effective as IV diazepam for treatment of acute seizures in children
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 40 min
Given medication(s)
copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2
Continuum of seizures
Abend et al PEC 2008
Febrile status epilepticus (FEBSTAT)
Seinfeld et al Epilepsia 2014
Total duration depends on
Time to AED initiation
Time from AED to seizure termination
Early intervention = shorter duration
Status epilepticus first line
Benzos
Benzos
Benzos
Status epilepticus second line
Yasiry and Shorvon Seizure 2014
Meta-analysis evaluating efficacy of 5 AED
in convulsive benzodiazepine-resistant
status epilepticus
Conclusion
Valproate levetiracetam and
phenobarbital first line after benzos
Evidence did not support phenytoin as
first line or routine lacosamide
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Outline Recent literature pertaining to
Seizures
Trauma
Bronchiolitis and asthma
Questions mluumarylandedu
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 2 minutes
Simple Complex
Febrile Seizures
6 months to 5 years
Generalized
Lasts lt 15 min
No recurrence
within 24 hours
Focal
Duration gt 15 min
Recurrence within
24 hours
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 2 minutes
0
2011 AAP Guidelines
Only for simple febrile seizures
SIMPLE If well-appearing normal neuro exam return to baseline
NO NEED FOR INVASIVE TESTING
COMPLEX
Less Clear
More concerning for underlying pathology
If well-appearing more conservative approach of little
benefit
Workup for complex febrile seizure
Imaging
Kimia et al Pediatr Emerg Care 2012
Diagnostic studies
Hardasmalani and Saber Pediatr Emerg Care 2012
Lumbar puncture
Fletcher and Sharieff West J Emerg Med 2013
First complex febrile seizure
Conclusion(s)
Emergent neuroimaging and extensive
diagnostic studies including LP may be
unnecessary for well-appearing children
without other signs or symptoms
Recurrent brief nonfocal seizure
particularly low risk for positive findings
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 15 min
Given medication
Which agent
Randomized control trial
IN midazolam vs IV diazepam
50 patients
1 month to 12 years
Seizure gt10 minutes
Which agent
Midazolam (IN)
Faster time to medication initiation
Shorter time hospital arrival to seizure control
Diazepam (IV)
Decrease interval from drug to seizure control
Conclusion
IN midazolam is as effective as IV diazepam for treatment of acute seizures in children
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 40 min
Given medication(s)
copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2
Continuum of seizures
Abend et al PEC 2008
Febrile status epilepticus (FEBSTAT)
Seinfeld et al Epilepsia 2014
Total duration depends on
Time to AED initiation
Time from AED to seizure termination
Early intervention = shorter duration
Status epilepticus first line
Benzos
Benzos
Benzos
Status epilepticus second line
Yasiry and Shorvon Seizure 2014
Meta-analysis evaluating efficacy of 5 AED
in convulsive benzodiazepine-resistant
status epilepticus
Conclusion
Valproate levetiracetam and
phenobarbital first line after benzos
Evidence did not support phenytoin as
first line or routine lacosamide
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 2 minutes
Simple Complex
Febrile Seizures
6 months to 5 years
Generalized
Lasts lt 15 min
No recurrence
within 24 hours
Focal
Duration gt 15 min
Recurrence within
24 hours
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 2 minutes
0
2011 AAP Guidelines
Only for simple febrile seizures
SIMPLE If well-appearing normal neuro exam return to baseline
NO NEED FOR INVASIVE TESTING
COMPLEX
Less Clear
More concerning for underlying pathology
If well-appearing more conservative approach of little
benefit
Workup for complex febrile seizure
Imaging
Kimia et al Pediatr Emerg Care 2012
Diagnostic studies
Hardasmalani and Saber Pediatr Emerg Care 2012
Lumbar puncture
Fletcher and Sharieff West J Emerg Med 2013
First complex febrile seizure
Conclusion(s)
Emergent neuroimaging and extensive
diagnostic studies including LP may be
unnecessary for well-appearing children
without other signs or symptoms
Recurrent brief nonfocal seizure
particularly low risk for positive findings
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 15 min
Given medication
Which agent
Randomized control trial
IN midazolam vs IV diazepam
50 patients
1 month to 12 years
Seizure gt10 minutes
Which agent
Midazolam (IN)
Faster time to medication initiation
Shorter time hospital arrival to seizure control
Diazepam (IV)
Decrease interval from drug to seizure control
Conclusion
IN midazolam is as effective as IV diazepam for treatment of acute seizures in children
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 40 min
Given medication(s)
copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2
Continuum of seizures
Abend et al PEC 2008
Febrile status epilepticus (FEBSTAT)
Seinfeld et al Epilepsia 2014
Total duration depends on
Time to AED initiation
Time from AED to seizure termination
Early intervention = shorter duration
Status epilepticus first line
Benzos
Benzos
Benzos
Status epilepticus second line
Yasiry and Shorvon Seizure 2014
Meta-analysis evaluating efficacy of 5 AED
in convulsive benzodiazepine-resistant
status epilepticus
Conclusion
Valproate levetiracetam and
phenobarbital first line after benzos
Evidence did not support phenytoin as
first line or routine lacosamide
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Simple Complex
Febrile Seizures
6 months to 5 years
Generalized
Lasts lt 15 min
No recurrence
within 24 hours
Focal
Duration gt 15 min
Recurrence within
24 hours
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 2 minutes
0
2011 AAP Guidelines
Only for simple febrile seizures
SIMPLE If well-appearing normal neuro exam return to baseline
NO NEED FOR INVASIVE TESTING
COMPLEX
Less Clear
More concerning for underlying pathology
If well-appearing more conservative approach of little
benefit
Workup for complex febrile seizure
Imaging
Kimia et al Pediatr Emerg Care 2012
Diagnostic studies
Hardasmalani and Saber Pediatr Emerg Care 2012
Lumbar puncture
Fletcher and Sharieff West J Emerg Med 2013
First complex febrile seizure
Conclusion(s)
Emergent neuroimaging and extensive
diagnostic studies including LP may be
unnecessary for well-appearing children
without other signs or symptoms
Recurrent brief nonfocal seizure
particularly low risk for positive findings
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 15 min
Given medication
Which agent
Randomized control trial
IN midazolam vs IV diazepam
50 patients
1 month to 12 years
Seizure gt10 minutes
Which agent
Midazolam (IN)
Faster time to medication initiation
Shorter time hospital arrival to seizure control
Diazepam (IV)
Decrease interval from drug to seizure control
Conclusion
IN midazolam is as effective as IV diazepam for treatment of acute seizures in children
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 40 min
Given medication(s)
copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2
Continuum of seizures
Abend et al PEC 2008
Febrile status epilepticus (FEBSTAT)
Seinfeld et al Epilepsia 2014
Total duration depends on
Time to AED initiation
Time from AED to seizure termination
Early intervention = shorter duration
Status epilepticus first line
Benzos
Benzos
Benzos
Status epilepticus second line
Yasiry and Shorvon Seizure 2014
Meta-analysis evaluating efficacy of 5 AED
in convulsive benzodiazepine-resistant
status epilepticus
Conclusion
Valproate levetiracetam and
phenobarbital first line after benzos
Evidence did not support phenytoin as
first line or routine lacosamide
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 2 minutes
0
2011 AAP Guidelines
Only for simple febrile seizures
SIMPLE If well-appearing normal neuro exam return to baseline
NO NEED FOR INVASIVE TESTING
COMPLEX
Less Clear
More concerning for underlying pathology
If well-appearing more conservative approach of little
benefit
Workup for complex febrile seizure
Imaging
Kimia et al Pediatr Emerg Care 2012
Diagnostic studies
Hardasmalani and Saber Pediatr Emerg Care 2012
Lumbar puncture
Fletcher and Sharieff West J Emerg Med 2013
First complex febrile seizure
Conclusion(s)
Emergent neuroimaging and extensive
diagnostic studies including LP may be
unnecessary for well-appearing children
without other signs or symptoms
Recurrent brief nonfocal seizure
particularly low risk for positive findings
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 15 min
Given medication
Which agent
Randomized control trial
IN midazolam vs IV diazepam
50 patients
1 month to 12 years
Seizure gt10 minutes
Which agent
Midazolam (IN)
Faster time to medication initiation
Shorter time hospital arrival to seizure control
Diazepam (IV)
Decrease interval from drug to seizure control
Conclusion
IN midazolam is as effective as IV diazepam for treatment of acute seizures in children
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 40 min
Given medication(s)
copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2
Continuum of seizures
Abend et al PEC 2008
Febrile status epilepticus (FEBSTAT)
Seinfeld et al Epilepsia 2014
Total duration depends on
Time to AED initiation
Time from AED to seizure termination
Early intervention = shorter duration
Status epilepticus first line
Benzos
Benzos
Benzos
Status epilepticus second line
Yasiry and Shorvon Seizure 2014
Meta-analysis evaluating efficacy of 5 AED
in convulsive benzodiazepine-resistant
status epilepticus
Conclusion
Valproate levetiracetam and
phenobarbital first line after benzos
Evidence did not support phenytoin as
first line or routine lacosamide
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
2011 AAP Guidelines
Only for simple febrile seizures
SIMPLE If well-appearing normal neuro exam return to baseline
NO NEED FOR INVASIVE TESTING
COMPLEX
Less Clear
More concerning for underlying pathology
If well-appearing more conservative approach of little
benefit
Workup for complex febrile seizure
Imaging
Kimia et al Pediatr Emerg Care 2012
Diagnostic studies
Hardasmalani and Saber Pediatr Emerg Care 2012
Lumbar puncture
Fletcher and Sharieff West J Emerg Med 2013
First complex febrile seizure
Conclusion(s)
Emergent neuroimaging and extensive
diagnostic studies including LP may be
unnecessary for well-appearing children
without other signs or symptoms
Recurrent brief nonfocal seizure
particularly low risk for positive findings
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 15 min
Given medication
Which agent
Randomized control trial
IN midazolam vs IV diazepam
50 patients
1 month to 12 years
Seizure gt10 minutes
Which agent
Midazolam (IN)
Faster time to medication initiation
Shorter time hospital arrival to seizure control
Diazepam (IV)
Decrease interval from drug to seizure control
Conclusion
IN midazolam is as effective as IV diazepam for treatment of acute seizures in children
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 40 min
Given medication(s)
copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2
Continuum of seizures
Abend et al PEC 2008
Febrile status epilepticus (FEBSTAT)
Seinfeld et al Epilepsia 2014
Total duration depends on
Time to AED initiation
Time from AED to seizure termination
Early intervention = shorter duration
Status epilepticus first line
Benzos
Benzos
Benzos
Status epilepticus second line
Yasiry and Shorvon Seizure 2014
Meta-analysis evaluating efficacy of 5 AED
in convulsive benzodiazepine-resistant
status epilepticus
Conclusion
Valproate levetiracetam and
phenobarbital first line after benzos
Evidence did not support phenytoin as
first line or routine lacosamide
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Workup for complex febrile seizure
Imaging
Kimia et al Pediatr Emerg Care 2012
Diagnostic studies
Hardasmalani and Saber Pediatr Emerg Care 2012
Lumbar puncture
Fletcher and Sharieff West J Emerg Med 2013
First complex febrile seizure
Conclusion(s)
Emergent neuroimaging and extensive
diagnostic studies including LP may be
unnecessary for well-appearing children
without other signs or symptoms
Recurrent brief nonfocal seizure
particularly low risk for positive findings
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 15 min
Given medication
Which agent
Randomized control trial
IN midazolam vs IV diazepam
50 patients
1 month to 12 years
Seizure gt10 minutes
Which agent
Midazolam (IN)
Faster time to medication initiation
Shorter time hospital arrival to seizure control
Diazepam (IV)
Decrease interval from drug to seizure control
Conclusion
IN midazolam is as effective as IV diazepam for treatment of acute seizures in children
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 40 min
Given medication(s)
copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2
Continuum of seizures
Abend et al PEC 2008
Febrile status epilepticus (FEBSTAT)
Seinfeld et al Epilepsia 2014
Total duration depends on
Time to AED initiation
Time from AED to seizure termination
Early intervention = shorter duration
Status epilepticus first line
Benzos
Benzos
Benzos
Status epilepticus second line
Yasiry and Shorvon Seizure 2014
Meta-analysis evaluating efficacy of 5 AED
in convulsive benzodiazepine-resistant
status epilepticus
Conclusion
Valproate levetiracetam and
phenobarbital first line after benzos
Evidence did not support phenytoin as
first line or routine lacosamide
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
First complex febrile seizure
Conclusion(s)
Emergent neuroimaging and extensive
diagnostic studies including LP may be
unnecessary for well-appearing children
without other signs or symptoms
Recurrent brief nonfocal seizure
particularly low risk for positive findings
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 15 min
Given medication
Which agent
Randomized control trial
IN midazolam vs IV diazepam
50 patients
1 month to 12 years
Seizure gt10 minutes
Which agent
Midazolam (IN)
Faster time to medication initiation
Shorter time hospital arrival to seizure control
Diazepam (IV)
Decrease interval from drug to seizure control
Conclusion
IN midazolam is as effective as IV diazepam for treatment of acute seizures in children
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 40 min
Given medication(s)
copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2
Continuum of seizures
Abend et al PEC 2008
Febrile status epilepticus (FEBSTAT)
Seinfeld et al Epilepsia 2014
Total duration depends on
Time to AED initiation
Time from AED to seizure termination
Early intervention = shorter duration
Status epilepticus first line
Benzos
Benzos
Benzos
Status epilepticus second line
Yasiry and Shorvon Seizure 2014
Meta-analysis evaluating efficacy of 5 AED
in convulsive benzodiazepine-resistant
status epilepticus
Conclusion
Valproate levetiracetam and
phenobarbital first line after benzos
Evidence did not support phenytoin as
first line or routine lacosamide
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 15 min
Given medication
Which agent
Randomized control trial
IN midazolam vs IV diazepam
50 patients
1 month to 12 years
Seizure gt10 minutes
Which agent
Midazolam (IN)
Faster time to medication initiation
Shorter time hospital arrival to seizure control
Diazepam (IV)
Decrease interval from drug to seizure control
Conclusion
IN midazolam is as effective as IV diazepam for treatment of acute seizures in children
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 40 min
Given medication(s)
copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2
Continuum of seizures
Abend et al PEC 2008
Febrile status epilepticus (FEBSTAT)
Seinfeld et al Epilepsia 2014
Total duration depends on
Time to AED initiation
Time from AED to seizure termination
Early intervention = shorter duration
Status epilepticus first line
Benzos
Benzos
Benzos
Status epilepticus second line
Yasiry and Shorvon Seizure 2014
Meta-analysis evaluating efficacy of 5 AED
in convulsive benzodiazepine-resistant
status epilepticus
Conclusion
Valproate levetiracetam and
phenobarbital first line after benzos
Evidence did not support phenytoin as
first line or routine lacosamide
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Which agent
Randomized control trial
IN midazolam vs IV diazepam
50 patients
1 month to 12 years
Seizure gt10 minutes
Which agent
Midazolam (IN)
Faster time to medication initiation
Shorter time hospital arrival to seizure control
Diazepam (IV)
Decrease interval from drug to seizure control
Conclusion
IN midazolam is as effective as IV diazepam for treatment of acute seizures in children
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 40 min
Given medication(s)
copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2
Continuum of seizures
Abend et al PEC 2008
Febrile status epilepticus (FEBSTAT)
Seinfeld et al Epilepsia 2014
Total duration depends on
Time to AED initiation
Time from AED to seizure termination
Early intervention = shorter duration
Status epilepticus first line
Benzos
Benzos
Benzos
Status epilepticus second line
Yasiry and Shorvon Seizure 2014
Meta-analysis evaluating efficacy of 5 AED
in convulsive benzodiazepine-resistant
status epilepticus
Conclusion
Valproate levetiracetam and
phenobarbital first line after benzos
Evidence did not support phenytoin as
first line or routine lacosamide
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Which agent
Midazolam (IN)
Faster time to medication initiation
Shorter time hospital arrival to seizure control
Diazepam (IV)
Decrease interval from drug to seizure control
Conclusion
IN midazolam is as effective as IV diazepam for treatment of acute seizures in children
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 40 min
Given medication(s)
copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2
Continuum of seizures
Abend et al PEC 2008
Febrile status epilepticus (FEBSTAT)
Seinfeld et al Epilepsia 2014
Total duration depends on
Time to AED initiation
Time from AED to seizure termination
Early intervention = shorter duration
Status epilepticus first line
Benzos
Benzos
Benzos
Status epilepticus second line
Yasiry and Shorvon Seizure 2014
Meta-analysis evaluating efficacy of 5 AED
in convulsive benzodiazepine-resistant
status epilepticus
Conclusion
Valproate levetiracetam and
phenobarbital first line after benzos
Evidence did not support phenytoin as
first line or routine lacosamide
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Case
2 yo male with seizure
VS 394 HR 130 RR 22 97
Exam drowsy but arousable
FS 101
Duration 40 min
Given medication(s)
copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2
Continuum of seizures
Abend et al PEC 2008
Febrile status epilepticus (FEBSTAT)
Seinfeld et al Epilepsia 2014
Total duration depends on
Time to AED initiation
Time from AED to seizure termination
Early intervention = shorter duration
Status epilepticus first line
Benzos
Benzos
Benzos
Status epilepticus second line
Yasiry and Shorvon Seizure 2014
Meta-analysis evaluating efficacy of 5 AED
in convulsive benzodiazepine-resistant
status epilepticus
Conclusion
Valproate levetiracetam and
phenobarbital first line after benzos
Evidence did not support phenytoin as
first line or routine lacosamide
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2
Continuum of seizures
Abend et al PEC 2008
Febrile status epilepticus (FEBSTAT)
Seinfeld et al Epilepsia 2014
Total duration depends on
Time to AED initiation
Time from AED to seizure termination
Early intervention = shorter duration
Status epilepticus first line
Benzos
Benzos
Benzos
Status epilepticus second line
Yasiry and Shorvon Seizure 2014
Meta-analysis evaluating efficacy of 5 AED
in convulsive benzodiazepine-resistant
status epilepticus
Conclusion
Valproate levetiracetam and
phenobarbital first line after benzos
Evidence did not support phenytoin as
first line or routine lacosamide
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Febrile status epilepticus (FEBSTAT)
Seinfeld et al Epilepsia 2014
Total duration depends on
Time to AED initiation
Time from AED to seizure termination
Early intervention = shorter duration
Status epilepticus first line
Benzos
Benzos
Benzos
Status epilepticus second line
Yasiry and Shorvon Seizure 2014
Meta-analysis evaluating efficacy of 5 AED
in convulsive benzodiazepine-resistant
status epilepticus
Conclusion
Valproate levetiracetam and
phenobarbital first line after benzos
Evidence did not support phenytoin as
first line or routine lacosamide
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Status epilepticus first line
Benzos
Benzos
Benzos
Status epilepticus second line
Yasiry and Shorvon Seizure 2014
Meta-analysis evaluating efficacy of 5 AED
in convulsive benzodiazepine-resistant
status epilepticus
Conclusion
Valproate levetiracetam and
phenobarbital first line after benzos
Evidence did not support phenytoin as
first line or routine lacosamide
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Status epilepticus second line
Yasiry and Shorvon Seizure 2014
Meta-analysis evaluating efficacy of 5 AED
in convulsive benzodiazepine-resistant
status epilepticus
Conclusion
Valproate levetiracetam and
phenobarbital first line after benzos
Evidence did not support phenytoin as
first line or routine lacosamide
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
ldquoNewerrdquo agents
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Vitamin ldquoKrdquo (keppra)
McTague et al Seizure 2012
Abend et at Seizure 2013
Bleck et al Epilepsia 2013
Established SE Trial
Fosphenytoin levetiracetam and valproic acid
Multicenter randomized double-blind
NETT and PECARN
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Vitamin ldquoKrdquo (ketamine)
NMDA receptor antagonist
Anti-epileptic properties neuroprotection
Gaspard et al Epilepsia 2013
Synowiec et al Epilepsy Res 2013
Rosati et al Neurology 2012
Kramer Neurocrit Care 2012
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
0-10 min (pre-hospital)
bull Midazolam 02 mgkg IN or IM
bull Midazolam 05 mgkg buccal
bull Diazepam 05 mgkg PR
10-20 min
bull Lorazepam 01 mgkg IV
bull 2+ doses
20-60 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
RSI
bull Ketamine 15-2 mgkg
bull Succinocholine vs roccuronium
60-90 min
bull Levetiracetam fosphenytoin valproic acid phenobarbital
bull ldquo20rdquo mgkg IV (repeat)
90-120 min
bull Midazolam propofol barbiturate drip
bull General anesthesia
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Neonatal seizures
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Management neonate
OXYGEN
Correct electrolytes
D10 (5 mLkg)
10 calcium gluconate (2 mLkg)
3 NaCl (5-10 mLkg)
Phenobarbital 20 mgkg
Can repeat dose if needed buthellip
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Management neonate
(Fos)Phenytoin 20 mgkg
Max rate 1 mgkgmin
Monitor cardiac rate and rhythm
Lorazepam 005 ndash 10 mgkg
Give in 005 mgkg increments over several minutes
Watch for respiratory depression
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Neonates do it all
Adults Children
HampP
+- labs LP CT
outpatient EEG
HampP
+- labs LP CT
outpatient EEG
Comparison
new onset afebrile seizure
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
And Donrsquot Forgethellip
Hypoglycemia
Rule of 50
Hyponatremia
5-10 mLkg 3 normal saline
Hypocalcemia
Calcium 60 to 100 mgkg IVIO
Isoniazid ingestion
Pyridoxine (vitamin B6)
unknown ingestion 70 mgkg IV (max 5 gm)
known ingestion 1 gmkg per 1 gm ingested
For neonates 100 mg (not weight based)
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Dextrose
Ill patients with depressed mental status
are hypoglycemic until proven otherwise
Treat for BS lt 50
Rule of 50
D10 5 mlkg (age lt 1 year)
D25 2 mlkg (age 1 ndash 8 year)
D50 1 mlkg (age gt 8 year)
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Seizure Precautions
Care around water
Heights
No motorized vehicles
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Take home points
Reconsider ldquofullrdquo workup for complex
febrile seizures
Early initiation of anti-epileptic drugs
Benzodiazepines are first line
Phenobarbital for neonates
Vitamin ldquoKrdquo
Check glucose early and often
lecturesumemorgAAEM
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
TRAUMA
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Age RR
Infant 30-60
Toddler 24-40
Preschooler 22-34
School-aged 18-30
Adolescent 12-16
gt 60
gt30
gt15
Pearls
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Circulation
Heart rate
Pulse quality
Capillary refill time
Skin temperature
Blood pressure
([2 x age] + 70)
[2 x age] + 90
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
[2 x age] + 90
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
abdominal tenderness
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Abdominal trauma
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Low risk
Ann Emerg Med 2012
Prospective observational cohort
20 EDs
Prediction rule to identify children with blunt
torso trauma at very low risk of intraabdominal
injuries requiring acute intervention
12044 children
761 (63) with intra-abdominal injuries
203 (267) received acute interventions
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Blunt abdominal injuries
Prediction rule
No evidence of abdominal wall trauma or seat
belt sign
Glasgow Coma Scale score gt13
No abdominal tenderness
No evidence of thoracic wall trauma
No complaints of abdominal pain
No decreased breath sounds and
No vomiting
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Blunt abdominal injuries
Results
NPV 999
Sensitivity 97
Specificity 425
Missed 65028 (01) with IAI
5 had lab abnormalities
All had hemoperitoneum
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Holmes et al Ann Emerg Med 2012
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury
Holmes et al Ann Emerg Med 2002
Labs
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Case
8 yo male involved in MVC
VS 374 HR 96 RR 18 BP 11085 97
Exam well-appearing no complaints
Abdominal tenderness elevated LFTs
CT scan negative
Dispo
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Blunt abdominal injuries
Conclusion
A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention
CT scan rarely misses clinically important blunt abdominal traumatic injuries
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Cervical spine
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Plain films for cervical spine
Nigrovic et al Pediatr Emerg Care 2012
PECARN
30x radiation CT vs plain films
Retrospective cohort
90 sensitivity for CSI (2+ views)
Higher for older children
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Cervical spine imaging
0 with normal neuro exam had missed
injuries requiring neurosurgical
intervention
Higher risk with normal radiographs
AMS
Intubation
Focal neuro deficit
Congenital cervical spine abnormality
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Cervical spine imaging
Conclusion
Two-view plain radiographs had high
sensitivity (90) for cervical spine injury
in pediatric patients
High risk patients may warrant advanced
imaging
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Head Injury
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
LOC
Vomited
15 mo
HR 130 RR 26 BP 7540 97
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Kupperman et al Lancet 2009
Age lt 2 years
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Kupperman et al Lancet 2009
Age ge 2 years
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Case
8 yo male head injury
VS HR 96 RR 18 BP 11085 97
Exam awake alert
Ondansetron
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Ondansetron
Sturm et al AJEM 2013
Retrospective cross-sectional study
Lower likelihood of 72 hour return
Use no effect on admission or returns
Rx no effect on returns or readmissions
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Ondansetron and head injury
Conclusion
Ondansetron did not mask symptoms and
decreased return visits to ED in children
who underwent CT and were discharged
home
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Image gently
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
One exceptionhellip
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Skeletal survey in abuse
Duffy et al Pediatrics 2011
2006 gt14000 child victims
703 consecutive patients
Retrospective descriptive study
Use of skeletal survey (SS) to identify children
most likely to have unsuspected fractures
How often SS results directly influence
diagnosis of abuse
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Skeletal survey in abuse
Positive SS result = previously unsuspected
fracture
703 SS 108 positive results
79 had gt1 healing fracture
Highest rates
lt 6 months
ALTE or seizure
Suspected abusive head trauma
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Skeletal survey in abuse
Conclusion
Almost 11 of SS positive
In 50 positive SS cases results directly
influenced the decision to make the
diagnosis of abuse
Obtain SS in infants lt6 months with
suspected abuse
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Take home points
Image gently
Clinical decision rules
LFTs for blunt abdominal trauma
If imaging negative ondansetron okay
If imaging negative safe to discharge
Be vigilant about NAT
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Summary so far
Seizures
Limited workup for complex febrile seizures
Know agents for status epilepticus
Trauma
Clinical decision rules (plus labs)
Image gently
Consider NAT
lecturesumemorgAAEM
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Respiratory
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 130 RR 26 BP 7540 94
Exam smiling wheezing mild retractions
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Skjerven et al NEJM 2013
Eight center randomized double-blind trial
404 infants
Conclusion
Inhaled racemic adrenaline is not more effective than inhaled saline
The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Case
15 month male with 3 day cough
congestion rhinorrhea
VS T 384 HR 150 RR 50 BP 7540 90
Exam wheezing mod retractions
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
High Flow Nasal Cannula
Wing et al Pediatr Emerg Care 2012
Retrospective
PED to PICU with ARI over 4 years
848 patients in 3 cohorts
228 HFNC
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Results
HFNC success rates
84 - 88
Decreased intubation rate
Decreased ventilator utilization by 50
No difference PICU LOS mortality or
mean duration of mechanical ventilation
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
HFNC
Conclusion
HFNC decreased need for intubation and
mechanical ventilator utilization for
children in the PED admitted to PICU
with ARI particularly when initiated early
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
HFNC ndash predicting intubation
Kelly et al Pediatr Emerg Care 2013
Retrospective review
Age lt 2 years
All causes respiratory distress
Predictors of success failure
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
HFNC ndash predicting intubation
Conclusions
Predictive of failure
triage RR gt 90th percentile for age
initial venous PCO2 gt 50 mm Hg
initial venous pH lt 730
Diagnosis of acute bronchiolitis was
protective with respect to intubation
following HFNC
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Heliox for bronchiolitis
Chowdhury et al Pediatrics 2013
Bronchiolitis Randomized Controlled Trial
Emergency-Assisted Therapy with
HelioxmdashAn Evaluation (BREATHE)
largest multicenter randomized
controlled trial investigating efficacy of
Heliox in acute bronchiolitis
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Heliox for bronchiolitis
Conclusion
Heliox therapy does not reduce length of
treatment unless given via a tightfitting
facemask or CPAP
Nasal cannula heliox therapy is ineffective
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Corticosteroid timing and length of stay for children with
asthma in the Emergency Department
Davis SR Burke G Hogan E Smith SR
Asthma
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Asthma and steroids
Conclusion
Early steroid administration decreases time to
clinical improvement and discharge and reduced
admission rates in children presenting with
moderate to severe acute asthma
exacerbations
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Steroids in asthma
Dexamethasone vs prednisone
Keeney et al Pediatrics 2014
Redman Arch Dis Children 2013
Williams et al Clin Pediatr 2013
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Steroids in asthma
Conclusions (dexamethasone)
Equal efficacy
Shorter duration of treatment
Less vomiting
Improved compliance
Parental preference
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Take home points
Racemic epi as effective as inhaled saline
Consider high flow nasal cannula in
patients with respiratory distress
Check the mask fit with heliox
Give steroids early for asthma
Dexamethasone gt prednisone
lecturesumemorgAAEM
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Summary so far
Seizures Limited work-up for CFS
Addition of vitamin ldquoKrdquo for status
Trauma Image gently
Consider NAT
Respiratory High flow nasal cannula decreases intubation
Early administration of steroids
lecturesumemorgAAEM
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Bonus
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Withdrawl of OTC CCM
Alternatives
Fluids
Humidified air
NSAIDS
Anti-histamines
Echinacea
Zinc
Honey
Vitamin C
25 mL qhs (gt1 year of age)
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Summary
Complex febrile seizures do not warrant
extensive diagnostic or imaging studies
Consider vitamin ldquoKrdquo for status epilepticus
Clinical decision rules for trauma
LFTs for blunt intraabdominal injury
Ondansetron for head injury safe
Early steroids for asthma
High flow nasal cannula decreases need for
intubation
lecturesumemorgAAEM
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Special thanks
Amal Mattu and Ghazala Sharieff
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]
Questions
mluumarylandedu
For a PDF copy of all slides go to
lecturesumemorgAAEM [will be posted after AAEM for 1 month]