Tweaks (of the Twade) in Pediatric Emergency Medicine

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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. gt 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 lt 3 month olds with
  bronchiolitis? Who do you test? Who do you
  admit?
• CHOA bronchiolitis guidelines remove those lt 1
  month from pathway
• Cincinnati Childrens guidelines state, healthy
  infants with bronchiolitis lt 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 cont
• ? admit all RSV infants lt 3 mo within 1st 72
  hours
• ? Admit all infants lt 3 mo with wheezing,
  retractions or tachypnea by history or exam in
  1st 72 hours

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Bronchiolitis

• PEM listserv cont
• ? No routine testing of infants lt 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 Ts
• 1 truncus (1 trunk)
• 2 transposition of the 2 great arteries
• 3 TRIcuspid atresia
• 4 TETRAlogy of Fallot
• 5 Total anomalous pulm venous return
• NOTE all have normal ECG except 3

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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/html
• http//www.cochrane.org/reviews
• http//www.bestbets.org
• http//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 suit
• 43 PEMs named in suit
• Of the suits,
• 33 dropped
• 36 settled
• 19 in progress
• 12 to trial.
• 75 MD wins, 25 plaintiff wins

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Medico legal issues in PEM

• 1 type of suit failure to diagnose
• TOP 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, residents
  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 gt 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 gt dont use
• Not straightforward diagnosis gt dont use
• lt 6 months gt dont 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 gt 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 lt 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 articles 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 lidocaine
• Bicarb buffer

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Wounds

• Remember railroad tracks on face
• TRICK if use Fast Absorbing Gut sutures still
  present gt 5 days, have them rub with soapy water
  and will break sutures

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Wounds

• Bites
• No dermabond
• Dog bites usually lt 20 infection rate,
• Cat bites usually lt 80
• Pasturella in about 80 of cat bites-
• CLINDA does not cover Pasturella. Augmentin,
  cefuroxime, and azithromycin dos
• Rabid 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