Pearl? or Fecalith?Myths and legends in paediatric

emergency and critical careLisa McQueen

@McQueenLisa

“The greater the ignorance, the greater the

dogmatism”-Sir William Osler

Lidocaine with epinephrine is contraindicated in a digital block

Pearl? or Fecalith?

2 RCTs, 103 patientsno complications9 hand surgeons

3,110 digital blocksNo infarction

No phentolamine rescue24 Doppler studies of arterial flow

All fully reversed120 years of medical literature21 cases of digital necrosis

None occur after commercial introduction of lidocaine with epi

Muck AE et al. Six years of epinephrine digital injections: absence of significant local or systemic effects. Annals EM 2010;270-274.

365 accidental injections

4 with ischemia

2 resolved within 2 hours

All resolved uneventfully

Lidocaine with epinephrine is contraindicated in a digital block

Fecalith

Drop atropine from your pediatric RSI strategy

Pearl? or Fecalith?

Infants have exaggerated parasympathetic tone

Laryngoscopy can make them bradycardic

Succinylcholine can make them bradycardic

Hypoxia makes them bradycardic

The treatment for hypoxia is not

atropine

Drop atropine from your pediatric RSI strategy

PEARL

Avoid fluoroquinolone antibiotics in children

Pearl? or Fecalith?

The Beagle Study• Beagle puppies given difloxacin or

placebo• Articular cartilage examined • Within 2 days, vesicles on articular

surface• Over time, dissolution of matrix and

necrosis of chondrocytes

Burkhardt et al. Histologic and biochemical changes in articular cartilages of immature beagle dogs dosed with difloxacin, a fluoroquinolone. Vet Pathology 1990;27:162-70.

Beagles are not Children• 1795 children who received 2030

treatment courses of ciprofloxacin• Arthralgia in 31 (1.5%)• 60% of these in children with

cystic fibrosis• Arthralgia resolved after

treatment course completed

Hampel et al. Ciprofloxacin in pediatrics: worldwide clinical experience based on compassionate use--safety report. Pediatric Infectious Disease Journal 1997;16:127-9.

Avoid fluoroquinolone antibiotics in children

Fecalith

Avoid aspirin in children to prevent Reye’s syndrome

Pearl? or Fecalith?

Belay ED et al. Reye's sydnrome in the United States from 1981 through 1997. NEJM 1999;340:1377-82.

Did Reye’s syndrome really exist?

Was Reye’s syndrome really from aspirin?

Orlowski JP et al. A catch in the Reye. Pediatrics 1987;80:638-42.

26 cases of Reye’s re-examined1 with aspirin

exposureNo cases after 1983

70% ultimately with

inborn error of metabolism

World-wide decline in influenza B severity

Diagnosis of MC FAOD

Avoid aspirin in children to prevent Reye’s syndrome

Fecalith

No need to use lidocaine for an infant lumbar puncture

Pearl? or Fecalith?

Larry Mellick. Increasing success with infant spinal taps. Emergency Medicine News. April 2013. http://journals.lww.com/em-news/blog/M2E/pages/post.aspx?PostID=11

Children are not little adults

Children are little humans