The best of_the_pem_literature_in_the_last_year_terry_klassen_presentation

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.


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.


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%


Inferences A structured intervention, tailored to

pain management shortcomings, may

lead to improvements


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)


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


Concluding thoughts

Advances in knowledge incremental

but significant

Each study adds something

There was clustering in certain areas

of concussion, appendicitis, pain and

asthma

The best of_the_pem_literature_in_the_last_year_terry_klassen_presentation

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