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The Best of the PEM
literature in the last year
Terry P Klassen, MD, MSc, FRCPC
CEO and Scientific Director, Manitoba Institute of Child Health
Associate Dean, Academic, Faculty of Medicine, University of Manitoba
PEM Review Course
Edmonton CPS meeting
June 18, 2013
2
A initiative to mobilize knowledge on best pediatric
emergency care
Brought to you by:
Approach
Mainly used 2012 as the last year
Journals searched:◦ Pediatrics
◦ Journal of Pediatrics
◦ Archives Disease Childhood
◦ JAMA Pediatrics
◦ Annals of Emergency Medicine
◦ Academic Emergency Medicine
◦ Pediatric Emergency Care
◦ JAMA
Approach continued
Pubmed, used term
“Pediatric Emergency
Medicine”
So some articles are from
2013
Criteria: interesting,
relevant, quality
Constipation #1 (or is it number
2) Seldom in these update talks
Few gravitate to it as their research
domain
? Poop phobia
Yet our younger patients love to talk
about it and important part of their
humour
Yet we know
It is common “Constipation is the most
common diagnosis in children
presenting with abdominal pain”
20% of patients
Pediatrics 2013;131:1098-1106.
Most have acute symptoms and get
better
Female, recurrent pain, duration (>2
days) and medical visit (Arch Pediatr
Adolesc Med 2000;154:1204-8)
RCT of PEG 3350 vs Enema for
fecal disimpaction in PED Intervention: Milk and molasses
enema (1:1, 10 mL/kg, max 500 mL)
in the ED or PEG 3350 (1.5
g/kg/d, max 100g/day) for 3 days
Maintenance: PEG 3350 (0.8
g/kg/day) for both groups
Telephone follow up days 1,3 and 5
days
Primary outcome: Symptom
improvementPed Emerg Care 2012;28:115
Results
79 patients (39 PEG; 40 enema)
Day 1, PEG patients less likely to
have improved symptoms
Half enema group upset in ED with
treatment vs none in PEG group
At Day 5, no differences between
groups
Most treatment failures in PEG group
(83%, p = 0.08)
Bottom line
Either approach has advantages and
disadvantages
Discussion with child/family for
preferences
More research needed in constipation
presenting to the ED
Appendicitis #2
We know from previously quoted
study, that 1 to 5% of children
presenting with abdominal pain will
have appendicitis
Who has not been burnt with this
diagnosis?
So what about the use of diagnostic
imaging adjuncts?
What about radiation from CT of
abdomen?
Temporal trends in radiographic testing among pediatric patients presenting to the ED with
abdominal pain.
Fahimi J et al. Pediatrics 2012;130:e1069-e1075
©2012 by American Academy of Pediatrics
Figure?2 Rates of CT and US in children with appendicitis at 40 pediatric EDs in the United States, 2005-2009.
Richard G. Bachur , Kara Hennelly , Michael J. Callahan , Michael C. Monuteaux
Advanced Radiologic Imaging for Pediatric Appendicitis, 2005-2009: Trends and Outcomes
The Journal of Pediatrics Volume 160, Issue 6 2012 1034 - 1038
http://dx.doi.org/10.1016/j.jpeds.2011.11.037
Figure?3 Association between the rate of advanced imaging (<ce:italic> x</ce:italic> -axis) and the rate of negative appendectomy
(<ce:italic> y</ce:italic> -axis) (weighted by the number of appendectomy procedures per hospital) in pediatric ED patients un...
Richard G. Bachur , Kara Hennelly , Michael J. Callahan , Michael C. Monuteaux
Advanced Radiologic Imaging for Pediatric Appendicitis, 2005-2009: Trends and Outcomes
The Journal of Pediatrics Volume 160, Issue 6 2012 1034 - 1038
http://dx.doi.org/10.1016/j.jpeds.2011.11.037
Appendicitis #2 Clinical practice guideline to help
stratify into low, medium and high risk
Low: WBC < 10,000 and polys <
67%, bands < 5%, absence of
guarding in RLQ or periumbilical
areas.
High: WBC > 10,000, > 67% presence
of guarding and/or focal tenderness in
RLQ or periumbilical area
Greater than 13 hours of painAcad Emerg Med 2012;19:886
Appendicitis #2 Low risk: home and follow up in 6 to
12 hours
Medium: Attending discretion but
imaging with ultrasound +/- CT scan
High risk: Refer to surgery
58% managed without CT, 37% went
to OR with no imaging
Rate of missed appendicitis, 2% and
negative appendectomy 1%
Acad Emerg Med 2012;19:886
Intussusception #3 Of course for the little ones, one
always worries about this possibility
308 patients with 12.3% with
intussusception
Factors lethargy at home and bloody
stools
Ped Emerg Care 2012;
© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 2
FIGURE 2
Ability of Pediatric Physicians to Judge the Likelihood of Intussusception.Weihmiller, Sarah; Monuteaux, Michael; Bachur, Richard
Pediatric Emergency Care. 28(2):136-140, February 2012.DOI: 10.1097/PEC.0b013e3182442db1
FIGURE 2 . Ability of physicians to predict a diagnosis of intussusception based on history and clinical examination. *Numbers in the bars represent actual patient numbers.
© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 2
FIGURE 1
Accuracy of Plain Radiographs to Exclude the Diagnosis of Intussusception.Roskind, Cindy; Kamdar, Gunjan; Ruzal-Shapiro, Carrie; Bennett, Jonathan; Dayan, Peter; MD, MSc
Pediatric Emergency Care. 28(9):855-858, September 2012.DOI: 10.1097/PEC.0b013e318267ea38
FIGURE 1 . Patient flow.
© 2012 Lippincott Williams & Wilkins, Inc. Published by Lippincott Williams & Wilkins, Inc. 2
TABLE 3
Accuracy of Plain Radiographs to Exclude the Diagnosis of Intussusception.Roskind, Cindy; Kamdar, Gunjan; Ruzal-Shapiro, Carrie; Bennett, Jonathan; Dayan, Peter; MD, MSc
Pediatric Emergency Care. 28(9):855-858, September 2012.DOI: 10.1097/PEC.0b013e318267ea38
TABLE 3 Test Characteristics of 3-View Abdominal Radiography in the Diagnosis of Intussusception When 2 or More of the 3 Views Have Air in the Ascending Colon
2
SPEAKING ABOUT PAIN…
2
Pain management in the PED
#4 Vulnerable population in both
diagnosis and treatment of pain
More likely to be inadequately treated
Communication barriers
Pain exposure may be harmful
Ped Emerg Care 2012;28:524-528
Approach Baseline data – identify areas of
deficiency and room for improvement
Multidisciplinary Committee
Intervention – next slide
Collection of post-intervention data
Ped Emerg Care 2012;28:28:524
Intervention Proper pain scales
Pain as 5th vital sign
Treatment with pharmacologic and
nonpharmacologic methods
Triage pathway for those with moderate
or severe pain to receive analgesics
immediately
Topical anesthetics and oral sucrose
Reassessment of pain
Discharge pain action plansPed Emerg Care 2012;28:28:524
Results Before (102) – after (109)
Increase in patients in pain receiving
analgesic 34 to 50%
Median time 97 minutes to 57 minutes
Reassessment of pain 6 to 76%
Ped Emerg Care 2012;28:28:524
Inferences A structured intervention, tailored to
pain management shortcomings, may
lead to improvements
Ped Emerg Care 2012;28:28:524
Concussion #5 Burgeoning research area –
professional athletes
Trickle down to the ED
Roger Zemek is our man in PERC
Rest does matter
49 young athletes
Prescribed 1 week of cognitive and
physical rest
Main outcome Concussion Symptoms
Scale ratings, Immediate Post-
Concussion Assessment and
Cognitive Testing
J Pediatr 2012;161:922-926
Outcome
Regardless of time post injury (weeks
to months)
Participants showed improved
performance on Immediate Post-
Concussion Assessment measure
It may be the cerebral blood flow 12 children with sports-related
concussion matched controls
No structural, metabolic, neuronal or
axonal injury.
Reduction in CBF that improved over
time
Pediatrics 2012;129:28-37
Critical procedures #6 25% of community EDs felt
uncomfortable performing potentially life saving procedures on children
In survey of pediatric ED medical directors 62% judged number of intubation opportunities as inadequate for providers to maintain competency
In one pediatric ED, survey of 114 children undergoing RSI, 48% failed first intubation attempt
Ann Emerg Med 2013; 61:263-270
Critical procedures in the PED 261 procedures during 194
resuscitations, which represented 0.22% of all ED patient evaluations
61% of PEM faculty did not perform a single critical procedure
Orotracheal intubation occurred 147 times (56%)
63% of PEM faculty did not perform a single intubation
PEM fellows median of 3 critical procedures
Ann Emerg Med 2013; 61:263-270
Critical procedures – 12
months Oratracheal intubation (147)
Intraosseous line placement (41)
Pharmacologic cardioversion (23)
Tube thoracotomy (18)
Central line (15)
Needle thoracostomy (9)
Electrocardioversion (6)
Defibrillation (1)
Pericardiocentesis (1)
Ann Emerg Med 2013; 61:263-270
RSI from video review 114 children undergoing RSI in ED in
the 12 months
52% of children were tracheally
intubated on first attempt
61% of subjects had 1 or more
adverse events during RSI
Ann Emerg Med 2013; 61:251-259
Figure 3 First-attempt success by physician type (n=subjects per type). “Attending” is comprised of both attending physicians from
Pediatric Emergency Medicine and providers from Anesthesiology. First attempt success was 88% (6 of 7 subjects) for PEM atten...
Benjamin T. Kerrey , Andrea S. Rinderknecht , Gary L. Geis , Lise E. Nigrovic , Matthew R. Mittiga
Rapid Sequence Intubation for Pediatric Emergency Patients: Higher Frequency of Failed Attempts and Adverse Effects
Found by Video Review
Annals of Emergency Medicine Volume 60, Issue 3 2012 251 - 259
Procalcitonin #7 Is it time to add this to your diagnostic
tool set?
Need to re-evaluate criteria to identify
infants at high risk of SPI with this as
criteria?
Diagnostic value in well-
appearing young febrile infants
Study performed in Spain (an
important part of REPEM and PERN)
1112 infants who had PCT measured
and blood culture performed
IBI diagnosed in 23 (2.1%)
PCT was only independent risk factor
for IBI (OR = 21.69 (7.63 to 59.28)
Pediatrics 2012;130:815-822
Receiver operating characteristic (ROC) curves to detect definite (A) SBIs and (B) IBIs.
Gomez B et al. Pediatrics 2012;130:815-822
©2012 by American Academy of Pediatrics
SR of topic
8 studies – 1,883 for procalcitonin
analysis
Ann Emerg Med 2012:60:591-600
Figure 3 Forest plot of diagnostic odds ratio for studies using PCT ( A ), C-reactive protein ( B ), or leukocyte count ( C ) to detect
SBI among children with fever without source.
Annals of Emergency Medicine Volume 60, Issue 5 2012 591 - 600
Asthma #8
Very common presenting problem
The more we can get children to stay
away from ED or get them out faster
with their acute asthma the better
Dex at the door
A time-series controlled trial
Physician initiated compared to nurse
initiated (4 months each)
N = 644
Pediatrics 2012;129:671-680
Dex at the door
Median time to improvement 24
minutes (1 to 50, P= 0.04)
Admission rate OR = 0.56, 0.36-0.8
Time to steroid decreased by 44
minutes , 17 to 68
Conclusion: Triage nurse initiated
steroid treatment reduced times to
clinical improvement and discharge
and reduced rate of admissionsPediatrics 2012;129:671-680
Supportive evidence
406 children, similar outcomes
Annals of Emerg Med 2012;60:84 to
91
Pediatrics 2012;129:671-680
Shaken baby syndrome # 9
Very challenging to identify suspected
abusive head trauma
So having a set of variables to look for
would be helpful
Pediatrics 2012;130:315-323
Systematic review
To determine clinical and radiographic
characteristics associated with
abusive head trauma (AHT) and
nonabusive head trauma (nAHT) in
children
24 studies included
No meta-analysis due to heterogeneity
of studies
19 variables identifiedPediatrics 2012;130:315-323
Variables associated with
AHT Subdural
hemorrhage
Cerebral ischemia
Cerebral edema*
Retinal
hemorrhage
Skull # occurring
with ICI
Metaphyseal
fractures
Long bone
fractures
Rib fractures
Any bruises*
Seizure within 24
hours
Apnea at
presentation
No adequate
history
Pediatrics 2012;130:315-323
Variables associated with nAHT
Epidural hemorrhage
Isolated skull fracture
Scalp swelling
Head and neck bruising (? Not when
high quality studies excluded)
Pediatrics 2012;130:315-323
To pack or not to pack? #10
After incision and drainage in the
PED, should a wound be packed?
Ped Emerg Care 2012;28:514
RCT on the question
RCT, single blind study
Randomized to packing vs not after
drainage
Treatment failure at 48 hours (masked
observer)
Ped Emerg Care 2012;28:514
Results
57 randomized over 15 month period
Failure rate 70% in packed group vs
59% in nonpacked group (11%, -15%
to 36%)
Bottom line: no evidence for packing
but small study
But key question for the future
Ped Emerg Care 2012;28:514
Concluding thoughts
Advances in knowledge incremental
but significant
Each study adds something
There was clustering in certain areas
of concussion, appendicitis, pain and
asthma