PEDIATRIC EMERGENCY MEDICINE LITERATURE REVIEW

“all the news that’s fit to print”

Richard M. Cantor, MD FAAP/FACEPProfessor of Emergency Medicine and Pediatrics

Section Chief, Pediatric Emergency MedicineDirector, Pediatric Emergency Medicine Fellowship

Golisano Children’s Hospital, Syracuse, NY

IS THERE TRUTH IN ……….

OUR ACE IN THE HOLE

WHY I CHOSE THESE ARTICLES

• They may provide new information

• They may confirm and validate what you are doing already

• They may be too ridiculous not to mention

PEDIATRICS 2018 140: 1

METHODS

• Children hospitalized with CAP in 6 children’s hospitals

• 3 months to 18 years of age

• Reviewed microbiologic data and classified positive blood culture detections as pathogens

RESULTS

• 7509 children

• 34% had a blood culture

• 65 (2.5%) grew a pathogen

RESULTS

CONCLUSIONS

• Among children without comorbidities hospitalized with CAP in a non-ICU setting, the rate of bacteremia was low, and isolated pathogens were usually susceptible to penicillin

• Blood cultures may not be needed for most children hospitalized with CAP

J Pediatr 2017;187:200-5

STUDY DESIGN

• 7 year study

• 29-56 days old with fever and who had an LP in the emergency department

• Low-risk criteria adapted from the Philadelphia criteria

LOW RISK CRITERIA

RESULTS

• 1 of 1188 febrile infants (0.08%) had BM; this patient did not meet low-risk criteria

• An additional 40 (3.4%) had positive cerebrospinal fluid cultures; all were contaminants

CONCLUSIONS

• In a cohort of febrile infants, BM is uncommon and no cases of BM would have been missed had LPs not been performed in those meeting low-risk criteria

Pediatr Emer Care 2018;34: 334–338

METHODS

• Infants < 3 months

• First held in standard lateral lumbar puncture position

• PEM physicians marked infants' backs at the level they would insert a needle using the landmark palpation technique

• A PEM sonologist imaged and measured the spinal fluid in 2 orthogonal planes at this marked level in lateral then sitting positions

• Fluid measurements were repeated by a second blinded PEM sonologist

RESULTS

• 46 infants enrolled

• Ultrasound verified the presence of fluid at the marked level as determined by the landmark palpation technique in 98% of cases

• Ultrasound identified additional suitable spaces 1 space higher (82%) and 2 spaces higher (41%)

LATERAL VS SITTING POSITIONS

CONCLUSIONS

• Ultrasound can verify the presence of fluid at interspaces determined by the landmark palpation technique and identify additional suitable spaces at higher levels

• There were statistically greater fluid measurements in sitting versus lateral positions

ACADEMIC EMERGENCY MEDICINE 2019;26:85–96

METHODS

• All randomized controlled trials comparing the success rates of ultrasound-assisted LP with landmark-based LP

• Secondary outcomes included the rate of traumatic LPs, time to procedural success, number of needle passes, and patient pain score

RESULTS

• Twelve studies (n = 957 total patients) were identified

• Ultrasound-assisted LP was successful in 90.0% of patients and landmark-based LP was successful in 81.4% of patients

• There were fewer traumatic LPs in the ultrasound-assisted group (10.7% vs. 26.5%

• Ultrasound-assisted LP was also associated with a shorter time to successful LP (6.87 minutes vs. 7.97 minutes), fewer mean needle passes (2.07 vs. 2.66), and lower patient pain scores (3.75 vs. 6.31)

CONCLUSIONS

• Ultrasound should be considered prior to performing all LPs, especially in patients with difficult anatomy

EVALUATION OF A NEW STRATEGY FOR

CLEAN-CATCH URINE IN INFANTS

PEDIATRICS Volume 138, number 3, September 2016:e20160573

METHODS

A prospective cohort study among infants <6 months needing a urine sample

Determined associations between successful urine samples and 4 predictive

factors (age, sex, low oral intake, and recent voiding)

TAPPING THE SUPRAPUBIC AREA

MASSAGING THE LUMBOSACRAL AREA

RESULTS

126 infants (64 boys, median age 55 days)

Procedure effective in 62 infants (median time: 45 seconds)

Success rates dropped off after 90 days

Contamination proportion 16% in the CCU group

not statistically different compared with the invasive method group

CONCLUSIONS

CCU procedure is a quick and effective noninvasive method in children aged <90

days

Contamination proportions were similar to those reported in the literature for urethral

catheterization

Circumstances for which the CCU procedure could be performed are

proposed

J Pediatr 2018;203:86-91

STUDY DESIGN

• Compared patient demographics, clinical, and laboratory findings, and prevalence of SBIs between virus-positive and virus-negative infants.

RESULTS

• 4778 enrolled infants• 2945 (61.6%) had viral

testing performed• 1200 (48.1%) were virus

positive• 44 of the 1200 had SBIs

(3.6%)

• 1745 virus-negative infants• 222 had SBIs (12.7%)

RESULTS

• Rates of specific SBIs in the virus-positive group vs the virus-negative group were

• UTIs (33 of 1200 = 2.8%); vs 186 of 1745 (10.7%)

• Bacteremia (9 of 1199 (0.8%) vs 50 of 1743 (2.8%)

• Negative viral status was significantly associated with SBI in multivariable analysis

CONCLUSIONS

• Febrile infants ≤60 days of age with viral infections are at significantly lower, but non-negligible risk for SBIs, including bacteremia and bacterial meningitis

Pediatr Emer Care 2018;34: 729–735

OBJECTIVES

• Evaluate the ordering of albuterol via metered-dose inhaler with spacer (MDI-spacer), length of stay (LOS), and 72-hour return rates before and after publication of an internally developed pediatric asthma clinical practice guideline (CPG)

RESULTS

• Albuterol delivery via MDI-spacer increased by 33.95% (P < 0.0001) during 1-month post-CPG implementation with no significant subsequent decrease

• For MDI- spacer–treated patients post-CPG, decreased median LOS was maintained and there was decreased variability of the median LOS (P < 0.001)

• For nebulizer-treated patients post-CPG, median LOS increased (.95 minutes; P = 0.033)

• No change was observed for 72-hour return rates

CONCLUSIONS

• Implementation of an asthma CPG increased ordering of albuterol via MDI-spacer

• Decreased variability in median LOS for MDI-spacer patients was observed post-CPG

• Median LOS for those treated with MDI-spacer exclusively remained unchanged in the post-CPG period, whereas post-CPG LOS increased in those who received nebulized albuterol

J Peds 201: 16 – 20. 2018

Pediatr Emer Care 2019;35: 28–31

RESULTS(2 YEAR STUDY)

• 250 charts reviewed• 84% (211) met the NIAID

criteria for anaphylaxis

• Only 68% of patients received epinephrine in the ED or within 3 hours of the ED visit

• Adherence was poor and IRR was variable, for measures reflecting documentation of discharge instructions and follow-up with a specialist

CONCLUSIONS

• Findings highlight a gap between best practice and ED care

• Results suggest that the NIAID criteria can reliably be used to retrospectively identify pediatric patients with anaphylaxis

Pediatr Emer Care 2018;34: 623–627

METHODS

• Retrospective chart review of children younger than 12 months presenting to an urban pediatric hospital and its suburban satellite for an ALTE from October 2009 to December 2012

• Exclusion criteria were known trauma and cases lacking an identi- fiable ALTE feature on review

RESULTS

• 617 cases met inclusion and exclusion criteria• 537 had a head CT performed• Five patients were identified

with clinically important head CT findings: a case of congenital toxoplasmosis, a case of intraventricular hemorrhage, and 3 cases of nonaccidental trauma (NAT)

• One of the NAT patients had a bruise on his forehead; the other patients had no historical, physical examination, and other laboratory or radiologic findings to raise concern for significant finding on head CT

CONCLUSIONS

• The rate of clinically important head CT findings in ALTE evaluation was relatively rare, at 0.93%

• Given the severe consequences of missing these cases, these data establish a role for empiric head CT in the evaluation of ALTE

Pediatrics. 72:586 – 588. 2018

Pediatrics. 2017;140(2)

METHODS

• Modeled 4 diagnostic imaging strategies

• (1) CT scan

• (2) fsMRI

• (3) screening ONSD by using point of care ultrasound (POCUS) first, combined with CT

• (4) screening ONSD by using POCUS first, combined with fsMRI

• All patients received an initial plain radiographic shunt series (SS)

• Effectiveness was measured as quality-adjusted life- years

RESULTS

• A screening POCUS in patients with a normal SS was the most cost-effective

• For children with abnormal SS or ONSD measurement, fsMRI was the preferred option over CT

• Performing fsMRI on all patients would cost $27,627 to gain 1 additional quality-adjusted life-year compared with CT

CONCLUSIONS

• In children with low pretest probability of cranial shunt failure, an ultrasonographic measurement of ONSD is the preferred initial screening test

• fsMRI is the more cost-effective, definitive imaging test when compared with cranial CT

Pediatr Emer Care 2017;33: 635–642

METHODS

• The primary outcomes analyzed were the times to first β-agonist and steroid administration

• Secondary outcomes included admission rate, ED length of stay, and ED revisits

RESULTS

• Assignment of the Pediatric Asthma Score

• Time to first β-agonist administration decreased from the baseline mean of 76 minutes to 27 minutes

• Time to steroid administration decreased from the baseline mean of 108 minutes to 49 minutes

• Mean monthly admission rate remained at 22% with no special cause variation identified

• The ED revisit rate was not negatively impacted and, in most months, was 0%

CONCLUSIONS

• By standardizing asthma care in our ED and redesigning care delivery processes, care variation decreased and significant improvements in timeliness of β-agonist and steroid administration occurred

N Engl J Med 378;24 2018

METHODS

• 13-center, randomized, controlled trial

• Examined the effects of the rate of administration and the sodium chloride content of intravenous fluids on neurologic outcomes in children with diabetic ketoacidosis

TREATMENT REGIMENS

METHODS

• The primary outcome was a decline in mental status during treatment for diabetic ketoacidosis

• Secondary outcomes included

• clinically apparent brain injury during treatment

• short-term memory during treatment

• memory and IQ 2 to 6 months after recovery from diabetic ketoacidosis

RESULTS

• 1389 episodes of diabetic ketoacidosis reported in 1255 children

• The Glasgow Coma Scale score declined to less than 14 in 48 episodes (3.5%), and clinically apparent brain injury occurred in 12 episodes (0.9%)

RESULTS

• No significant differences among the treatment groups were observed with respect to

• the percentage of episodes in which the Glasgow Coma Scale score declined to below 14

• the magnitude of decline in the Glasgow Coma Scale score

• the duration of time in which the Glasgow Coma Scale score was less than 14

RESULTS

• Memory and IQ scores obtained after the children’s recovery from diabetic ketoacidosis also did not differ significantly among the groups

• Serious adverse events other than altered mental status were rare and occurred with similar frequency in all treatment groups

CONCLUSIONS

• Neither the rate of administration nor the sodium chloride content of intravenous fluids significantly influenced neurologic outcomes in children with diabetic ketoacidosis

Pediatr Emer Care 2017;33: e108–e113

METHODS

• Primary outcome was the predictive ability of bicarbonate for the individual components of the composite outcome that included at least one of the following:• intensive care unit admission• assisted ventilation• inotropic support• cardiopulmonary resuscitation• death

• Secondary outcome was the relationship between bicarbonate level of greater and less than 13 mEq/L and the composite outcome

RESULTS

• 16,989 charts, 432 had an adverse outcome

• A bicarbonate level less than 18.5 mEq/L predicted inotropic support and death

• Significantly more patients with bicarbonate level of less than 13 mEq/L had at least 1 adverse outcome compared with those with bicarbonate level of greater than 13 mEq/L

RESULTS

CONCLUSIONS

• Among children presenting to the ED, a bicarbonate level of 18.5 mEq/L had fair specificity in predicting inotropic support and death

• Negative outcomes are significantly associated with bicarbonate level of less than 13 mEq/L

• Bicarbonate should routinely be measured in children at risk of clinical deterioration

Pediatr Emer Care 2018;34: 227–232

METHODS

• Evaluated a protocol prompting triage nurses to assess dehydration in gastroenteritis patients and initiate ondansetron and ORT if indicated

• Otherwise well patients aged 6 months to 5 years with symptoms of gastroenteritis were eligible

RESULTS

• 128 (81 postintervention and 47 preintervention) patients were analyzed; average age was 2.1 years

• Ondansetron use increased from 36% to 75%

• Time to ondansetron decreased from 60 minutes to 30 minutes

• Documented ORT increased from 51% to 100%

RESULTS

• Blood testing decreased from 37% to 21%

• Intravenous fluid decreased from 23% to 9%

• There were no significant changes in ED length of stay, admissions, or unscheduled return to care

CONCLUSIONS

• A triage nurse initiated protocol for early use of oral ondansetron and ORT in children with evidence of gastroenteritis is associated with increased and earlier use of ondansetron and ORT and decreased use of IV fluids and blood testing without lengthening ED stays or increasing rates of admission or unscheduled return to care

Pediatr Emer Care 2018;34: 422–425

METHODS

• Retrospective chart review of quality assurance database of RVs for radiology callbacks over a 1-year period

RESULTS

• Return visit rate was 3% of which 1.9% was for radiology callbacks

• Radiology misses involved mostly x-ray interpretations (92.7%), occurred after-hours (83.6%), with fractures being the most common missed finding

• Majority of patients (94.5%) required 1 or more interventions during the RV; 34.5% of radiology callbacks had a major impact on clinical management; 27.2% of radiology callbacks were false-positive

CONCLUSIONS

• Although RVs secondary to radiology callback remain low, one third of them resulted in major changes in diagnosis, treatment, or disposition and impacted patient outcome

Pediatr Emer Care 2018;34: 463–466

METHODS

• Medical records of children evaluated for torticollis from 2008 to 2013 were reviewed

RESULTS

Twenty- five patients (6.4%) were hospitalized

392 identified patients61% had postural

torticollis

19.4% infection related

16.3% traumatic

RESULTS

• Four variables were strongly and independently related to the severe outcome:

• Fever

• Sore throat

• Headache

• Age

• The association of 2 or 3 of these 4 features carried a risk of 32% and 58%, respectively, of having a severe illness

J Pediatr 2017;191:179-83

OBJECTIVE

• To identify the reasons why pediatric gastroenterologists obtain abdominal radiographs in the man-agement of pediatric constipation

REASONS FOR OBTAINING A RADIOGRAPH

RESULTS

• The plan was changed in 47.6% of cases based on radiographic findings

• In cases in which a plan was outlined before obtaining the radiograph (69%), the initial plan was implemented on average in 52.5%

• In cases with no plans before obtaining the radiograph, previously unconsidered plans were implemented in 8.7%

CONCLUSION

• The majority of Peds GI Docs used it to make a diagnosis, and nearly one-half changed their management based on the imaging findings

• Overall, they reported an improved confidence in their management plan, despite evidence that radiographic findings poorly correlate with clinical severity

JAMA Pediatr. 2017;171(10):957-964

DESIGN,SETTING,AND PARTICIPANTS

• Conducted in 6 pediatric emergency departments

• Children 18 years or younger who received sedation for a painful emergency department procedure were enrolled in the study

• 6295 (65.1%) were included in the final analysis

MAIN OUTCOMES AND MEASURES

• Four outcomes were examined:

• SAEs

• Significant interventions performed in response to an adverse event

• Oxygen desaturation

• Vomiting

LANDSCAPE

RESULTS

• Mean age was 8.0

• Adverse events occurred in 736 patients (11.7%)

• Oxygen desaturation (353 patients [5.6%]) and vomiting (328 [5.2%]) were the most common of these adverse events

• There were 69 SAEs (1.1%), and 86 patients (1.4%;) had a significant intervention

RESULTS

• Use of ketamine hydrochloride alone resulted in the lowest incidence of SAEs (17 [0.4%]) and significant interventions (37 [0.9%])

• Compared with ketamine alone, propofol alone and the combinations of ketamine and fentanyl citrate) and ketamine and propofol) had the highest incidence of SAEs

• The combinations of ketamine and fentanyl and ketamine and propofolhad the highest incidence of significant interventions

CONCLUSIONS AND RELEVANCE

• The incidence of adverse sedation outcomes varied significantly with type of sedation medication

• Use of ketamine only was associated with the best outcomes, resulting in significantly fewer SAEs and interventions than ketamine combined with propofolor fentanyl

And Finally:

ARTICLES TOO STRANGE NOT TO MENTION

I COULDN’T MAKE THIS UP:

PART ONE

• Measuring the Transrectal Diameter on Point-of-Care Ultrasound to Diagnose Constipation in

Children

I COULDN’T MAKE THIS UP:

PART TWO

• Painless Pediatric Priapism and Cough

Pediatric Emergency Care 2015 31:36

CRAZIEST SENTENCE IN AN ARTICLE

• “We present a 10-year-old child who presented with stuttering priapism of unknown etiology, which was ultimately associated with M pneumoniae.”

I COULDN’T MAKE THIS UP:

PART THREE

I COULDN’T MAKE THIS UP:

PART FOUR

• Uranus

DUMBEST ARTICLE TITLE (TO DATE)

DUMBEST TITLE

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