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Tweaks (of the Twade) in Pediatric Emergency Medicine
April 2006
Laurie J. Burton, MD
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ASTHMA
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ASTHMA
Pulses paradoxus is a fairly good measure of degree of obstruction. “> 12-14” indicates “severe”
Automatic device to measure PP, not requiring cooperative child
Steroids work as anti-inflammatory agents but also add more beta receptors for albuterol, even in the 1st 1-2 hours
“10 minute difference” of iv versus oral steroids
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ASTHMA
Noncompliant or vomiting patients- consider dexamethasone 0.6mg/kg x 1
Magnesium dosing at other institutions is 50-75mg/kg iv over 20 minutes, a little higher than our 40mg/kg iv
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BRONCHIOLITIS
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BRONCHIOLITIS
What about the newborns ie < 3 month olds with bronchiolitis? Who do you test? Who do you admit?
CHOA bronchiolitis guidelines remove those < 1 month from pathway
Cincinnati Children’s guidelines state, “healthy infants with bronchiolitis < 3 mo are at particular risk for hospitalization”
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Bronchiolitis
88% apnea occurs in the 1st 48 hours, Kneyber 1998
PEM listserv…? admit all RSV+ or clinical bronchiolitis
under 4 weeks of age who present within 1st 48 hours
? admit all RSV + infants with significant risk factors eg chronic lung, congenital heart
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Bronchiolitis
Natural course:? Usually past the worst at day 5 (unless
complication)18% still symptomatic at 3 weeks
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Bronchiolitis
PEM listserv con’t? admit all RSV + infants < 3 mo within 1st
72 hours? Admit all infants < 3 mo with wheezing,
retractions or tachypnea by history or exam in 1st 72 hours
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Bronchiolitis
PEM listserv con’t… ? No routine testing of infants < 3 mo without
history of apnea or lower tract signs or symptoms
Recent study showing po dexamethasone may decrease hospitalization at 4 h (44% vs 19%)
Current multicenter trial (including CHOA) which may answer some of these questions
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ECGS/ CARDIO
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ECGS / CARDIOLOGY
all emergency department ECGs should be reviewed by a pediatric cardiologist
One study showed 11/16 ECGs thought minor by PEM were major by Peds Cardio
24/94 thought no F/U needed by PEM thought F/U needed by Peds Cardio
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ECGs / Cardiology
Cyanotic newborn:Trick to remember the 5 T’s1 = truncus (1 trunk)2 = transposition of the 2 great arteries3 = TRIcuspid atresia4 = TETRAlogy of Fallot5 = Total anomalous pulm venous returnNOTE: all have normal ECG except #3
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ECGs / Cardiology
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EVIDENCE BASED MEDICINE
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Evidence Based Medicine
Definition:There is a management question, and in
this decision goes the following… High quality evidence MD experience Patient & MD preference Pathophysiologic reasoning
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Evidence Based Medicine
Some great websites (free)
http://researchinpem.homestead.com
/homepage/htmlhttp://www.cochrane.org/reviewshttp://www.bestbets.orghttp://www.guideline.gov
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TYLENOL OVERDOSE
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Tylenol overdose
Nomogram based on tylenol with a narcotic (eg T3, Percocet, Vicodyn), delayed gastric emptying
Loading dose of 20mg/kg po plain tylenol is perfectly safe
Peak for plain tylenol ingestion probably 2 hours, not 4 hours
NAC can be used even beyond 48 hours
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MEDICOLEGAL ISSUES
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Medico legal issues in PEM
27% pediatricians named in suit43% PEMs named in suitOf the suits,
33% dropped 36% settled 19% in progress 12% to trial….
• 75% MD wins, 25% plaintiff wins
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Medico legal issues in PEM
#1 type of suit = failure to diagnoseTOP CAUSES:
Appendicitis, meningitis, myocarditis Wounds & lacerations, dehydration SCFE, testicular torsion
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Medico legal issues in PEM
High risk patients: Previous visit same problem Multiple caregivers Inconsolable child Fever and abdominal pain
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Medico legal issues in PEM
Marc Gorelick, “Never say ‘just’ and ‘virus’ in the same sentence.”
No false reassurances
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Medico legal issues in PEM
MD pitfalls: Not reading RNs notes, EMS reports, resident’s
notes Ignoring abnormal vital signs Trusting the residents Not listening to the nurses
Remember, “just sit down” campaign- never act rushed
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REHYDRATION / ZOFRAN
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Rehydration/ Zofran
Clinically we overestimate the level of dehydration. -Lancet study
WHO criteria: Oral rehydration:
irritable, sunken, no tears, dry mm, slow turgor IV rehydration:
lethargic/floppy, very sunken, no tears, very dry mm, unable to drink
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Rehydration/ Zofran
CONTRAINDICATIONS to oral rehydration: Cardiovascular instability Surgical abdomen Na > 160 meq/L Parental fatigue
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Rehydration/ Zofran
Oral rehydration solutions have Na 80meq/L but taste is unacceptable
Pedialyte maintenance solutions have Na 50meq/L
Gatorade sports solutions have lower Na and higher glucose
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Rehydration/ Zofran
Academic calculation of oral rehydration amount: 50ml/kg over 4-6 hours Add maintenance (same as iv calculation) Add losses
5-10ml/kg for each diarrheal stool 2-3ml/kg for each emesis
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Rehydration/ Zofran
What a lot of ED folks do…
5-10ml every 2-5 minutes, 15-30 minute initial trial
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Rehydration/ Zofran
Reasonable recommendations for Zofran… Not dehydrated => don’t use Not straightforward diagnosis => don’t use < 6 months => don’t use (less clear if AGE)
AAP publication recommendation
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Rehydration/ Zofran
Zofran prescriptions (Anecdotal info)Example- 4mg ODT, dispense 2
Private insurance co-pay $15 Medicaid covers, no charge One pharmacy did not feel comfortable filling in
an 8 month old, “too young” CVS charges $54.59 self pay HSCH patient said the 8mg was going to cost
“Four hundred dollars” ????
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PAIN / SEDATION
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Pain / Sedation
Reminder that 1 procedure with poor control of pain => memory can last a lifetime
Particularly important in “naïve” child who will be undergoing multiple painful procedures in the future eg newly diagnosed leukemic etc
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Pain / Sedation
Routine use of po Versed as anxiolytic (not conscious sedation) of children < 4 yo with lacerations, especially to the face
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WOUNDS
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Wounds
Case 1 –
12 yo laceration to forearm 15cm x 3cm
Weight is 30 kg
Would you use LET?
How much is your maximum dose of lidocaine with epi you can use if you use LET?
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Wounds
Using LET is often worthwhile on extremities
If you use LET, then use no more than 5mg/kg lidocaine with epinephrine by injection One article’s recommendation
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Wounds
NO STERI-STRIPS WITH DERMABOND- The child may pick off the strips and the
dermabond may come off with it
NO BATHING AND SWIMMING WITH DERMABOND Shower is fine
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Wounds
Suture kits at HSCH and EG have 27G & 25G needle, much less painful with 27G
Slow injection of lidocaineBicarb buffer
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Wounds
Remember railroad tracks on face –
TRICK: if use Fast Absorbing Gut & sutures still present > 5 days, have them rub with soapy water and will break sutures
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Wounds
Bites: No dermabond Dog bites: usually < 20% infection rate, Cat bites usually < 80% Pasturella in about 80% of cat bites- CLINDA does not cover Pasturella. Augmentin,
cefuroxime, and azithromycin dosRabid cats now outnumber rabid dogs
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Wounds
Case 2
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Wounds
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Wounds
This is what happened….
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THE END