Pediatric Emergency Playbook

PEMplaybook.org

PEMplaybook.org

Does Your Patient Have Streptococcal Pharyngitis? No Problem -- I'll just Swab. Not So Fast...   Fagan Nomogram for Likelihood Ratios 1. Decide on your pre-test probability of the disease (choose an approximate probability based on our assessment) 2. Use the likelihood ratio that correlates to your exam. 3. Draw a straight line frm your pre-test probability starting point, to the LR of the feauture/test, take it through to find your post-test probability 4. Use this new post-test probability to help in your decision Your patient has palatal petechiae, which confers a positive likelihood ratio (LR+) of 2.7 See below how to use this statistic based on your clinical assessment" Low Probability Moderate Probability High Probability   List of Likelihood Ratios for Streptococcal Pharyngitis Symptoms and signs Positive LR (95% CI) Negative LR (95% CI) Sensitivity (95% CI) Specificity (95% CI) Scarlatiniform rash 3.91 (2.00-7.62) 0.94 (0.90-0.97) 0.08 (0.05-0.14) 0.98 (0.95-0.99) Pala

How do we make the diagnosis? What now?   Concussion in Sport Group Guidelines Concussion Recognition Tool (for coaches, trainers on field) Child Sports Concussion Assessment Tool, 5th Ed. (Child SCAT); Ages 5-12 Sports Concussion Assessment Tool, 5th Ed. (SCAT5); Ages 13 and Up This post and podcast are dedicated to the great K Kay Moody, DO, MPH for her stalwart effort to care for both patient and doctor. Thank you for all that you do to help us to be our best and for promoting #FOAMed #FOAMped and #MedEd. References Churchill NW et al. The first week after concussion: Blood flow, brain function and white matter microstructure. Neuroimage Clin. 2017; 14: 480–489. Ellis MJ et al. Psychiatric outcomes after pediatric sports-related concussion. J Neurosurg Pediatr. 2015; 16:709-718. Graham R et al. and the Committee on Sports-Related Concussions in Youth; Board on Children, Youth, and Families; Institute of Medicine; National Research Council. Sports-Related Concussions in Youth: Improving the Science, Changin

PEMplaybook.org

PEMplaybook.org

  References Baracco R et al. Pediatric Hypertensive Emergencies. Curr Hypertens Rep. 2014; 16:456. Belsha CW. Pediatric Hypertension in the Emergency Department. Ann Emerg Med. 2008; 51(3):21-24. Chandar J et al. Hypertensive crisis in children. Pediatr Nephrol. 2012; 27:741-751. Dionne JM et al. Hypertension Canada’s 2017 Guidelines for the Diagnosis, Assessment, Prevention, and Treatment of Pediatric Hypertension. Canadian J Cardiol. 2017; 33:577-585 *Flynn JT, Kaelber DC, Baker-Smith CM, et al; SUBCOMMITTEE ON SCREENING AND MANAGEMENT OF HIGH BLOOD PRESSURE IN CHILDREN. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017; 140(3):e20171904 Gilhotra Y et al. Blood pressure measurements on children in the emergency department. Emergency Medicine Australasia. 2006; 18:148-154. Lurbe E et al. 2016 European Society of Hypertension guidelines for the management of high blood pressure in children and a

A Social Visit or Your Most Dangerous Presentation Tonight? [Details in Audio] This post and podcast are dedicated to Henry Goldstein, B.Pharm, MBBS for his tireless dedication to all things #FOAMed, #FOAMped, and #MedEd.  You are awesome.  Make sure to visit Don't Forget the Bubbles! References Cohen GM, Albertini LW. Colic. Pediatr Rev. 2012; 33(7):332-3. Friedman SB et al. The crying infant: diagnostic testing and frequency of serious underlying disease. Pediatrics. 2009; 123(3):841-8 Herman M, Le A. The crying infant. Emerg Med Clin North Am. 2007 Nov;25(4):1137-59. Poole SR. The infant with acute, unexplained, excessive crying. Pediatrics. 1991; 88 (3): 450-5. Prentiss KA, Dorfman DH. Pediatric Opthalmology in the Emergency Department. Emerg. Med. Clin. N. Am. 2008; 26: 181-198. Shope TR, Rieg TS, Kathiria NN. Corneal abrasions in young infants. Pediatrics. 2010 Mar;125(3):e565-9. Epub 2010 Feb 8.

You know how to intubate safely.  You can recite all of the Ps backwards and forwards. Until you can't. Real-time trouble-shooting. [Details in Audio] This post and podcast are dedicated to Mads Astvad for sharing his enthusiasm, clinical excellence, and #FOAMed warrior spirit. Tak, min ven!  #SMACConia #Vikingeblod

Ovarian torsion is like the MI of the pelvis.  Sometimes all it takes is a good story to investigate. When to worry, when to walk it off, and when to work it up:     What is the typical presentation of ovarian torsion? There is none.  The presentation varies so much, we need a rule to live by: Unilateral pelvic pain in a girl is ovarian torsion until proven otherwise.  This includes the cases in which you are concerned about appendicitis.  They both can be fake-outs. Often the pain is severe and abrupt, but trying to tease this out is often not fruitful. Here are the often-reported signs and symptoms associated with ovarian torsion: Stabbing pain, 70% Nausea and vomiting, 70% Sudden, sharp pain in the lower abdomen, 59% Pain radiating to the back, flank, or groin, 51% Peritoneal signs, 3% Fever, less than 2% And of course…no pain on presentation…30%...intermittent torsion. What is the mechanism of ovarian torsion? Structurally abnormal ovary (including cysts) that causes the ovary to flop over and twist on i

Dogma often dictates routine care. There are times when we have to attend to paradigm shifts. An easy way to save lives?  Just say no to (these) drugs: Codeine Normally metabolized into codeine-6-glucuronide (50-70%) and norcodeine (10-15%).  Codeine, codeine-6-glucuronide, and norcodeine have low affinity for the μ (mu) receptor. However, the most active metabolite of codeine is morphine with 200x the affinity for the mu receptor as the codeine derivates.  The problem is, people vary in its metabolism from 0-15% of codeine is metabolized to morphine. Ok, codeine is lame at best, unpredictable at worst. True.  Unless you are hiding a genetic time bomb. You're an ultra-rapid metabolizer. Some people have multiple extra copies of the DNA sequence for the CYP2D6 enzyme.  Ultra rapid metabolizers funnel a huge proportion of their codeine into morphine metabolism, resulting in a bolus of morphine, ending in apnea. Promethazine with codeine This combination is no better than placebo -- all of the risks, with no pr

Not all head trauma is minor. Not all minor head trauma is clinically significant.   How can we sort out the overtly ok from the sneakily serious?     Mnemonics for bedside risk stratification of minor pediatric blunt head trauma, based on PECARN studies: [Details in Audio]   Blunt Head Trauma in Children < 2 years of Age     Blunt Head Trauma in Children ≥ 2 years of Age     Image Gently Campaign   Medical Imaging Record (maintain like an immunization card)   Brochure for Parents: Just in Time Education   Selected References Dayan PS et al. Association of Traumatic Brain Injuries with Vomiting in Children with Blunt Head Trauma. Ann Emerg Med. 2014; 63(6):657-665. Dayan PS et al. Headache in Traumatic Brain Injuries from Blunt Head Trauma. Pediatrics. 2015; 135(3):504-512. Horeczko T, Kuppermann N. To scan or not to scan: pediatric minor head trauma in your office, clinic or emergency department. Contemporary Pediatrics. 2012;29(8):40-47. Kupperman et al. Identification of children at very low risk of cl

Comfortable with G-tubes, tracheostomies, and VP shunts? Good.  Get ready for the next level: Vagus Nerve Stimulators, Intrathecal Pumps, and Ventricular Assist Devices.   Details in Audio: Vagus Nerve Stimulators For intractable epilepsy; sends retrograde signal up corona radiata Also may be used in: depression, bulimia, Alzheimer, narcolepsy, addiction, and others VNS magnets Are VNS safe in MRI? Are VNS safe in everyday life? Intrathecal Pumps Used to infuse basal rate of drug, usually baclofen for spasticity, but pump may contain morphine, bupivicaine, clonidine.  Also used for severe MS, stroke, TBI, chronic pain.  Verify the medication and identify the toxidrome if symptomatic. Ventricular Assist Devices May be left ventricular assist, right ventricular assist, or biventricular assist device.   References Vagus Nerve Stimulators (VNS) Elliott RE, Rodgers SD, Bassani L et al. Vagus nerve stimulation for children with treatment-resistant epilepsy: a consecutive series of 141 cases. J Neurosurg Pedia

PEMplaybook.org

Abdominal pain is common; so are strongly held myths and legends about what is concerning, and what is not.   One of our largest responsibilities in the Emergency Department is sorting out benign from surgical or medical causes of abdominal pain.  Morbidity and mortality varies by age and condition.   Abdominal Surgical Emergencies in Children: A Relative Timeline General Advice Neonate (birth to one month) Necrotizing Enterocolitis Pneumatosis Intestinalis. Essentials: Typically presents in 1st week of life (case reports to 6 months in chronically ill children) Extend suspicion longer in NICU graduates Up to 10% of all cases of necrotizing enterocolitis are in full-term children Pathophysiology is unknown, but likely a translocation of bacteria Diagnosis: Feeding intolerance, abdominal distention Abdominal XR: pneumatosis intestinalis Management: IV access, NG tube, broad-spectrum antibiotics, surgery consult, ICU admission Intestinal Malrotation with Volvulus Essentials: Corkscrew Sign i