Best of the Best in

Pediatrics

Recent Articles Yoursquove Got

to Know

Mimi Lu MD FAAEM Clinical Assistant Professor

Assistant Residency Program Director

Director Pediatric Emergency Medicine Education

University of Maryland School of Medicine

Baltimore Maryland

No relevant financial disclosures

Mimi Lu MD FAAEM Clinical Assistant Professor

Assistant Residency Program Director

Director Pediatric Emergency Medicine Education

University of Maryland School of Medicine

Baltimore Maryland

Outline Recent literature pertaining to

Seizures

Trauma

Bronchiolitis and asthma

Questions mluumarylandedu

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 2 minutes

Simple Complex

Febrile Seizures

6 months to 5 years

Generalized

Lasts lt 15 min

No recurrence

within 24 hours

Focal

Duration gt 15 min

Recurrence within

24 hours

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 2 minutes

0

2011 AAP Guidelines

Only for simple febrile seizures

SIMPLE If well-appearing normal neuro exam return to baseline

NO NEED FOR INVASIVE TESTING

COMPLEX

Less Clear

More concerning for underlying pathology

If well-appearing more conservative approach of little

benefit

Workup for complex febrile seizure

Imaging

Kimia et al Pediatr Emerg Care 2012

Diagnostic studies

Hardasmalani and Saber Pediatr Emerg Care 2012

Lumbar puncture

Fletcher and Sharieff West J Emerg Med 2013

First complex febrile seizure

Conclusion(s)

Emergent neuroimaging and extensive

diagnostic studies including LP may be

unnecessary for well-appearing children

without other signs or symptoms

Recurrent brief nonfocal seizure

particularly low risk for positive findings

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 15 min

Given medication

Which agent

Randomized control trial

IN midazolam vs IV diazepam

50 patients

1 month to 12 years

Seizure gt10 minutes

Which agent

Midazolam (IN)

Faster time to medication initiation

Shorter time hospital arrival to seizure control

Diazepam (IV)

Decrease interval from drug to seizure control

Conclusion

IN midazolam is as effective as IV diazepam for treatment of acute seizures in children

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 40 min

Given medication(s)

copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2

Continuum of seizures

Abend et al PEC 2008

Febrile status epilepticus (FEBSTAT)

Seinfeld et al Epilepsia 2014

Total duration depends on

Time to AED initiation

Time from AED to seizure termination

Early intervention = shorter duration

Status epilepticus first line

Benzos

Benzos

Benzos

Status epilepticus second line

Yasiry and Shorvon Seizure 2014

Meta-analysis evaluating efficacy of 5 AED

in convulsive benzodiazepine-resistant

status epilepticus

Conclusion

Valproate levetiracetam and

phenobarbital first line after benzos

Evidence did not support phenytoin as

first line or routine lacosamide

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

No relevant financial disclosures

Mimi Lu MD FAAEM Clinical Assistant Professor

Assistant Residency Program Director

Director Pediatric Emergency Medicine Education

University of Maryland School of Medicine

Baltimore Maryland

Outline Recent literature pertaining to

Seizures

Trauma

Bronchiolitis and asthma

Questions mluumarylandedu

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 2 minutes

Simple Complex

Febrile Seizures

6 months to 5 years

Generalized

Lasts lt 15 min

No recurrence

within 24 hours

Focal

Duration gt 15 min

Recurrence within

24 hours

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 2 minutes

0

2011 AAP Guidelines

Only for simple febrile seizures

SIMPLE If well-appearing normal neuro exam return to baseline

NO NEED FOR INVASIVE TESTING

COMPLEX

Less Clear

More concerning for underlying pathology

If well-appearing more conservative approach of little

benefit

Workup for complex febrile seizure

Imaging

Kimia et al Pediatr Emerg Care 2012

Diagnostic studies

Hardasmalani and Saber Pediatr Emerg Care 2012

Lumbar puncture

Fletcher and Sharieff West J Emerg Med 2013

First complex febrile seizure

Conclusion(s)

Emergent neuroimaging and extensive

diagnostic studies including LP may be

unnecessary for well-appearing children

without other signs or symptoms

Recurrent brief nonfocal seizure

particularly low risk for positive findings

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 15 min

Given medication

Which agent

Randomized control trial

IN midazolam vs IV diazepam

50 patients

1 month to 12 years

Seizure gt10 minutes

Which agent

Midazolam (IN)

Faster time to medication initiation

Shorter time hospital arrival to seizure control

Diazepam (IV)

Decrease interval from drug to seizure control

Conclusion

IN midazolam is as effective as IV diazepam for treatment of acute seizures in children

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 40 min

Given medication(s)

copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2

Continuum of seizures

Abend et al PEC 2008

Febrile status epilepticus (FEBSTAT)

Seinfeld et al Epilepsia 2014

Total duration depends on

Time to AED initiation

Time from AED to seizure termination

Early intervention = shorter duration

Status epilepticus first line

Benzos

Benzos

Benzos

Status epilepticus second line

Yasiry and Shorvon Seizure 2014

Meta-analysis evaluating efficacy of 5 AED

in convulsive benzodiazepine-resistant

status epilepticus

Conclusion

Valproate levetiracetam and

phenobarbital first line after benzos

Evidence did not support phenytoin as

first line or routine lacosamide

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Outline Recent literature pertaining to

Seizures

Trauma

Bronchiolitis and asthma

Questions mluumarylandedu

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 2 minutes

Simple Complex

Febrile Seizures

6 months to 5 years

Generalized

Lasts lt 15 min

No recurrence

within 24 hours

Focal

Duration gt 15 min

Recurrence within

24 hours

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 2 minutes

0

2011 AAP Guidelines

Only for simple febrile seizures

SIMPLE If well-appearing normal neuro exam return to baseline

NO NEED FOR INVASIVE TESTING

COMPLEX

Less Clear

More concerning for underlying pathology

If well-appearing more conservative approach of little

benefit

Workup for complex febrile seizure

Imaging

Kimia et al Pediatr Emerg Care 2012

Diagnostic studies

Hardasmalani and Saber Pediatr Emerg Care 2012

Lumbar puncture

Fletcher and Sharieff West J Emerg Med 2013

First complex febrile seizure

Conclusion(s)

Emergent neuroimaging and extensive

diagnostic studies including LP may be

unnecessary for well-appearing children

without other signs or symptoms

Recurrent brief nonfocal seizure

particularly low risk for positive findings

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 15 min

Given medication

Which agent

Randomized control trial

IN midazolam vs IV diazepam

50 patients

1 month to 12 years

Seizure gt10 minutes

Which agent

Midazolam (IN)

Faster time to medication initiation

Shorter time hospital arrival to seizure control

Diazepam (IV)

Decrease interval from drug to seizure control

Conclusion

IN midazolam is as effective as IV diazepam for treatment of acute seizures in children

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 40 min

Given medication(s)

copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2

Continuum of seizures

Abend et al PEC 2008

Febrile status epilepticus (FEBSTAT)

Seinfeld et al Epilepsia 2014

Total duration depends on

Time to AED initiation

Time from AED to seizure termination

Early intervention = shorter duration

Status epilepticus first line

Benzos

Benzos

Benzos

Status epilepticus second line

Yasiry and Shorvon Seizure 2014

Meta-analysis evaluating efficacy of 5 AED

in convulsive benzodiazepine-resistant

status epilepticus

Conclusion

Valproate levetiracetam and

phenobarbital first line after benzos

Evidence did not support phenytoin as

first line or routine lacosamide

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 2 minutes

Simple Complex

Febrile Seizures

6 months to 5 years

Generalized

Lasts lt 15 min

No recurrence

within 24 hours

Focal

Duration gt 15 min

Recurrence within

24 hours

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 2 minutes

0

2011 AAP Guidelines

Only for simple febrile seizures

SIMPLE If well-appearing normal neuro exam return to baseline

NO NEED FOR INVASIVE TESTING

COMPLEX

Less Clear

More concerning for underlying pathology

If well-appearing more conservative approach of little

benefit

Workup for complex febrile seizure

Imaging

Kimia et al Pediatr Emerg Care 2012

Diagnostic studies

Hardasmalani and Saber Pediatr Emerg Care 2012

Lumbar puncture

Fletcher and Sharieff West J Emerg Med 2013

First complex febrile seizure

Conclusion(s)

Emergent neuroimaging and extensive

diagnostic studies including LP may be

unnecessary for well-appearing children

without other signs or symptoms

Recurrent brief nonfocal seizure

particularly low risk for positive findings

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 15 min

Given medication

Which agent

Randomized control trial

IN midazolam vs IV diazepam

50 patients

1 month to 12 years

Seizure gt10 minutes

Which agent

Midazolam (IN)

Faster time to medication initiation

Shorter time hospital arrival to seizure control

Diazepam (IV)

Decrease interval from drug to seizure control

Conclusion

IN midazolam is as effective as IV diazepam for treatment of acute seizures in children

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 40 min

Given medication(s)

copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2

Continuum of seizures

Abend et al PEC 2008

Febrile status epilepticus (FEBSTAT)

Seinfeld et al Epilepsia 2014

Total duration depends on

Time to AED initiation

Time from AED to seizure termination

Early intervention = shorter duration

Status epilepticus first line

Benzos

Benzos

Benzos

Status epilepticus second line

Yasiry and Shorvon Seizure 2014

Meta-analysis evaluating efficacy of 5 AED

in convulsive benzodiazepine-resistant

status epilepticus

Conclusion

Valproate levetiracetam and

phenobarbital first line after benzos

Evidence did not support phenytoin as

first line or routine lacosamide

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Simple Complex

Febrile Seizures

6 months to 5 years

Generalized

Lasts lt 15 min

No recurrence

within 24 hours

Focal

Duration gt 15 min

Recurrence within

24 hours

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 2 minutes

0

2011 AAP Guidelines

Only for simple febrile seizures

SIMPLE If well-appearing normal neuro exam return to baseline

NO NEED FOR INVASIVE TESTING

COMPLEX

Less Clear

More concerning for underlying pathology

If well-appearing more conservative approach of little

benefit

Workup for complex febrile seizure

Imaging

Kimia et al Pediatr Emerg Care 2012

Diagnostic studies

Hardasmalani and Saber Pediatr Emerg Care 2012

Lumbar puncture

Fletcher and Sharieff West J Emerg Med 2013

First complex febrile seizure

Conclusion(s)

Emergent neuroimaging and extensive

diagnostic studies including LP may be

unnecessary for well-appearing children

without other signs or symptoms

Recurrent brief nonfocal seizure

particularly low risk for positive findings

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 15 min

Given medication

Which agent

Randomized control trial

IN midazolam vs IV diazepam

50 patients

1 month to 12 years

Seizure gt10 minutes

Which agent

Midazolam (IN)

Faster time to medication initiation

Shorter time hospital arrival to seizure control

Diazepam (IV)

Decrease interval from drug to seizure control

Conclusion

IN midazolam is as effective as IV diazepam for treatment of acute seizures in children

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 40 min

Given medication(s)

copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2

Continuum of seizures

Abend et al PEC 2008

Febrile status epilepticus (FEBSTAT)

Seinfeld et al Epilepsia 2014

Total duration depends on

Time to AED initiation

Time from AED to seizure termination

Early intervention = shorter duration

Status epilepticus first line

Benzos

Benzos

Benzos

Status epilepticus second line

Yasiry and Shorvon Seizure 2014

Meta-analysis evaluating efficacy of 5 AED

in convulsive benzodiazepine-resistant

status epilepticus

Conclusion

Valproate levetiracetam and

phenobarbital first line after benzos

Evidence did not support phenytoin as

first line or routine lacosamide

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 2 minutes

0

2011 AAP Guidelines

Only for simple febrile seizures

SIMPLE If well-appearing normal neuro exam return to baseline

NO NEED FOR INVASIVE TESTING

COMPLEX

Less Clear

More concerning for underlying pathology

If well-appearing more conservative approach of little

benefit

Workup for complex febrile seizure

Imaging

Kimia et al Pediatr Emerg Care 2012

Diagnostic studies

Hardasmalani and Saber Pediatr Emerg Care 2012

Lumbar puncture

Fletcher and Sharieff West J Emerg Med 2013

First complex febrile seizure

Conclusion(s)

Emergent neuroimaging and extensive

diagnostic studies including LP may be

unnecessary for well-appearing children

without other signs or symptoms

Recurrent brief nonfocal seizure

particularly low risk for positive findings

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 15 min

Given medication

Which agent

Randomized control trial

IN midazolam vs IV diazepam

50 patients

1 month to 12 years

Seizure gt10 minutes

Which agent

Midazolam (IN)

Faster time to medication initiation

Shorter time hospital arrival to seizure control

Diazepam (IV)

Decrease interval from drug to seizure control

Conclusion

IN midazolam is as effective as IV diazepam for treatment of acute seizures in children

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 40 min

Given medication(s)

copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2

Continuum of seizures

Abend et al PEC 2008

Febrile status epilepticus (FEBSTAT)

Seinfeld et al Epilepsia 2014

Total duration depends on

Time to AED initiation

Time from AED to seizure termination

Early intervention = shorter duration

Status epilepticus first line

Benzos

Benzos

Benzos

Status epilepticus second line

Yasiry and Shorvon Seizure 2014

Meta-analysis evaluating efficacy of 5 AED

in convulsive benzodiazepine-resistant

status epilepticus

Conclusion

Valproate levetiracetam and

phenobarbital first line after benzos

Evidence did not support phenytoin as

first line or routine lacosamide

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

2011 AAP Guidelines

Only for simple febrile seizures

SIMPLE If well-appearing normal neuro exam return to baseline

NO NEED FOR INVASIVE TESTING

COMPLEX

Less Clear

More concerning for underlying pathology

If well-appearing more conservative approach of little

benefit

Workup for complex febrile seizure

Imaging

Kimia et al Pediatr Emerg Care 2012

Diagnostic studies

Hardasmalani and Saber Pediatr Emerg Care 2012

Lumbar puncture

Fletcher and Sharieff West J Emerg Med 2013

First complex febrile seizure

Conclusion(s)

Emergent neuroimaging and extensive

diagnostic studies including LP may be

unnecessary for well-appearing children

without other signs or symptoms

Recurrent brief nonfocal seizure

particularly low risk for positive findings

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 15 min

Given medication

Which agent

Randomized control trial

IN midazolam vs IV diazepam

50 patients

1 month to 12 years

Seizure gt10 minutes

Which agent

Midazolam (IN)

Faster time to medication initiation

Shorter time hospital arrival to seizure control

Diazepam (IV)

Decrease interval from drug to seizure control

Conclusion

IN midazolam is as effective as IV diazepam for treatment of acute seizures in children

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 40 min

Given medication(s)

copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2

Continuum of seizures

Abend et al PEC 2008

Febrile status epilepticus (FEBSTAT)

Seinfeld et al Epilepsia 2014

Total duration depends on

Time to AED initiation

Time from AED to seizure termination

Early intervention = shorter duration

Status epilepticus first line

Benzos

Benzos

Benzos

Status epilepticus second line

Yasiry and Shorvon Seizure 2014

Meta-analysis evaluating efficacy of 5 AED

in convulsive benzodiazepine-resistant

status epilepticus

Conclusion

Valproate levetiracetam and

phenobarbital first line after benzos

Evidence did not support phenytoin as

first line or routine lacosamide

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Workup for complex febrile seizure

Imaging

Kimia et al Pediatr Emerg Care 2012

Diagnostic studies

Hardasmalani and Saber Pediatr Emerg Care 2012

Lumbar puncture

Fletcher and Sharieff West J Emerg Med 2013

First complex febrile seizure

Conclusion(s)

Emergent neuroimaging and extensive

diagnostic studies including LP may be

unnecessary for well-appearing children

without other signs or symptoms

Recurrent brief nonfocal seizure

particularly low risk for positive findings

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 15 min

Given medication

Which agent

Randomized control trial

IN midazolam vs IV diazepam

50 patients

1 month to 12 years

Seizure gt10 minutes

Which agent

Midazolam (IN)

Faster time to medication initiation

Shorter time hospital arrival to seizure control

Diazepam (IV)

Decrease interval from drug to seizure control

Conclusion

IN midazolam is as effective as IV diazepam for treatment of acute seizures in children

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 40 min

Given medication(s)

copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2

Continuum of seizures

Abend et al PEC 2008

Febrile status epilepticus (FEBSTAT)

Seinfeld et al Epilepsia 2014

Total duration depends on

Time to AED initiation

Time from AED to seizure termination

Early intervention = shorter duration

Status epilepticus first line

Benzos

Benzos

Benzos

Status epilepticus second line

Yasiry and Shorvon Seizure 2014

Meta-analysis evaluating efficacy of 5 AED

in convulsive benzodiazepine-resistant

status epilepticus

Conclusion

Valproate levetiracetam and

phenobarbital first line after benzos

Evidence did not support phenytoin as

first line or routine lacosamide

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

First complex febrile seizure

Conclusion(s)

Emergent neuroimaging and extensive

diagnostic studies including LP may be

unnecessary for well-appearing children

without other signs or symptoms

Recurrent brief nonfocal seizure

particularly low risk for positive findings

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 15 min

Given medication

Which agent

Randomized control trial

IN midazolam vs IV diazepam

50 patients

1 month to 12 years

Seizure gt10 minutes

Which agent

Midazolam (IN)

Faster time to medication initiation

Shorter time hospital arrival to seizure control

Diazepam (IV)

Decrease interval from drug to seizure control

Conclusion

IN midazolam is as effective as IV diazepam for treatment of acute seizures in children

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 40 min

Given medication(s)

copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2

Continuum of seizures

Abend et al PEC 2008

Febrile status epilepticus (FEBSTAT)

Seinfeld et al Epilepsia 2014

Total duration depends on

Time to AED initiation

Time from AED to seizure termination

Early intervention = shorter duration

Status epilepticus first line

Benzos

Benzos

Benzos

Status epilepticus second line

Yasiry and Shorvon Seizure 2014

Meta-analysis evaluating efficacy of 5 AED

in convulsive benzodiazepine-resistant

status epilepticus

Conclusion

Valproate levetiracetam and

phenobarbital first line after benzos

Evidence did not support phenytoin as

first line or routine lacosamide

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 15 min

Given medication

Which agent

Randomized control trial

IN midazolam vs IV diazepam

50 patients

1 month to 12 years

Seizure gt10 minutes

Which agent

Midazolam (IN)

Faster time to medication initiation

Shorter time hospital arrival to seizure control

Diazepam (IV)

Decrease interval from drug to seizure control

Conclusion

IN midazolam is as effective as IV diazepam for treatment of acute seizures in children

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 40 min

Given medication(s)

copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2

Continuum of seizures

Abend et al PEC 2008

Febrile status epilepticus (FEBSTAT)

Seinfeld et al Epilepsia 2014

Total duration depends on

Time to AED initiation

Time from AED to seizure termination

Early intervention = shorter duration

Status epilepticus first line

Benzos

Benzos

Benzos

Status epilepticus second line

Yasiry and Shorvon Seizure 2014

Meta-analysis evaluating efficacy of 5 AED

in convulsive benzodiazepine-resistant

status epilepticus

Conclusion

Valproate levetiracetam and

phenobarbital first line after benzos

Evidence did not support phenytoin as

first line or routine lacosamide

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Which agent

Randomized control trial

IN midazolam vs IV diazepam

50 patients

1 month to 12 years

Seizure gt10 minutes

Which agent

Midazolam (IN)

Faster time to medication initiation

Shorter time hospital arrival to seizure control

Diazepam (IV)

Decrease interval from drug to seizure control

Conclusion

IN midazolam is as effective as IV diazepam for treatment of acute seizures in children

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 40 min

Given medication(s)

copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2

Continuum of seizures

Abend et al PEC 2008

Febrile status epilepticus (FEBSTAT)

Seinfeld et al Epilepsia 2014

Total duration depends on

Time to AED initiation

Time from AED to seizure termination

Early intervention = shorter duration

Status epilepticus first line

Benzos

Benzos

Benzos

Status epilepticus second line

Yasiry and Shorvon Seizure 2014

Meta-analysis evaluating efficacy of 5 AED

in convulsive benzodiazepine-resistant

status epilepticus

Conclusion

Valproate levetiracetam and

phenobarbital first line after benzos

Evidence did not support phenytoin as

first line or routine lacosamide

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Which agent

Midazolam (IN)

Faster time to medication initiation

Shorter time hospital arrival to seizure control

Diazepam (IV)

Decrease interval from drug to seizure control

Conclusion

IN midazolam is as effective as IV diazepam for treatment of acute seizures in children

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 40 min

Given medication(s)

copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2

Continuum of seizures

Abend et al PEC 2008

Febrile status epilepticus (FEBSTAT)

Seinfeld et al Epilepsia 2014

Total duration depends on

Time to AED initiation

Time from AED to seizure termination

Early intervention = shorter duration

Status epilepticus first line

Benzos

Benzos

Benzos

Status epilepticus second line

Yasiry and Shorvon Seizure 2014

Meta-analysis evaluating efficacy of 5 AED

in convulsive benzodiazepine-resistant

status epilepticus

Conclusion

Valproate levetiracetam and

phenobarbital first line after benzos

Evidence did not support phenytoin as

first line or routine lacosamide

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Case

2 yo male with seizure

VS 394 HR 130 RR 22 97

Exam drowsy but arousable

FS 101

Duration 40 min

Given medication(s)

copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2

Continuum of seizures

Abend et al PEC 2008

Febrile status epilepticus (FEBSTAT)

Seinfeld et al Epilepsia 2014

Total duration depends on

Time to AED initiation

Time from AED to seizure termination

Early intervention = shorter duration

Status epilepticus first line

Benzos

Benzos

Benzos

Status epilepticus second line

Yasiry and Shorvon Seizure 2014

Meta-analysis evaluating efficacy of 5 AED

in convulsive benzodiazepine-resistant

status epilepticus

Conclusion

Valproate levetiracetam and

phenobarbital first line after benzos

Evidence did not support phenytoin as

first line or routine lacosamide

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

copy 2008 Lippincott Williams amp Wilkins Inc Published by Lippincott Williams amp Wilkins Inc 2

Continuum of seizures

Abend et al PEC 2008

Febrile status epilepticus (FEBSTAT)

Seinfeld et al Epilepsia 2014

Total duration depends on

Time to AED initiation

Time from AED to seizure termination

Early intervention = shorter duration

Status epilepticus first line

Benzos

Benzos

Benzos

Status epilepticus second line

Yasiry and Shorvon Seizure 2014

Meta-analysis evaluating efficacy of 5 AED

in convulsive benzodiazepine-resistant

status epilepticus

Conclusion

Valproate levetiracetam and

phenobarbital first line after benzos

Evidence did not support phenytoin as

first line or routine lacosamide

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Febrile status epilepticus (FEBSTAT)

Seinfeld et al Epilepsia 2014

Total duration depends on

Time to AED initiation

Time from AED to seizure termination

Early intervention = shorter duration

Status epilepticus first line

Benzos

Benzos

Benzos

Status epilepticus second line

Yasiry and Shorvon Seizure 2014

Meta-analysis evaluating efficacy of 5 AED

in convulsive benzodiazepine-resistant

status epilepticus

Conclusion

Valproate levetiracetam and

phenobarbital first line after benzos

Evidence did not support phenytoin as

first line or routine lacosamide

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Status epilepticus first line

Benzos

Benzos

Benzos

Status epilepticus second line

Yasiry and Shorvon Seizure 2014

Meta-analysis evaluating efficacy of 5 AED

in convulsive benzodiazepine-resistant

status epilepticus

Conclusion

Valproate levetiracetam and

phenobarbital first line after benzos

Evidence did not support phenytoin as

first line or routine lacosamide

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Status epilepticus second line

Yasiry and Shorvon Seizure 2014

Meta-analysis evaluating efficacy of 5 AED

in convulsive benzodiazepine-resistant

status epilepticus

Conclusion

Valproate levetiracetam and

phenobarbital first line after benzos

Evidence did not support phenytoin as

first line or routine lacosamide

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

ldquoNewerrdquo agents

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Vitamin ldquoKrdquo (keppra)

McTague et al Seizure 2012

Abend et at Seizure 2013

Bleck et al Epilepsia 2013

Established SE Trial

Fosphenytoin levetiracetam and valproic acid

Multicenter randomized double-blind

NETT and PECARN

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Vitamin ldquoKrdquo (ketamine)

NMDA receptor antagonist

Anti-epileptic properties neuroprotection

Gaspard et al Epilepsia 2013

Synowiec et al Epilepsy Res 2013

Rosati et al Neurology 2012

Kramer Neurocrit Care 2012

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

0-10 min (pre-hospital)

bull Midazolam 02 mgkg IN or IM

bull Midazolam 05 mgkg buccal

bull Diazepam 05 mgkg PR

10-20 min

bull Lorazepam 01 mgkg IV

bull 2+ doses

20-60 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

RSI

bull Ketamine 15-2 mgkg

bull Succinocholine vs roccuronium

60-90 min

bull Levetiracetam fosphenytoin valproic acid phenobarbital

bull ldquo20rdquo mgkg IV (repeat)

90-120 min

bull Midazolam propofol barbiturate drip

bull General anesthesia

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Neonatal seizures

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Management neonate

OXYGEN

Correct electrolytes

D10 (5 mLkg)

10 calcium gluconate (2 mLkg)

3 NaCl (5-10 mLkg)

Phenobarbital 20 mgkg

Can repeat dose if needed buthellip

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Management neonate

(Fos)Phenytoin 20 mgkg

Max rate 1 mgkgmin

Monitor cardiac rate and rhythm

Lorazepam 005 ndash 10 mgkg

Give in 005 mgkg increments over several minutes

Watch for respiratory depression

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Neonates do it all

Adults Children

HampP

+- labs LP CT

outpatient EEG

HampP

+- labs LP CT

outpatient EEG

Comparison

new onset afebrile seizure

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

And Donrsquot Forgethellip

Hypoglycemia

Rule of 50

Hyponatremia

5-10 mLkg 3 normal saline

Hypocalcemia

Calcium 60 to 100 mgkg IVIO

Isoniazid ingestion

Pyridoxine (vitamin B6)

unknown ingestion 70 mgkg IV (max 5 gm)

known ingestion 1 gmkg per 1 gm ingested

For neonates 100 mg (not weight based)

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Dextrose

Ill patients with depressed mental status

are hypoglycemic until proven otherwise

Treat for BS lt 50

Rule of 50

D10 5 mlkg (age lt 1 year)

D25 2 mlkg (age 1 ndash 8 year)

D50 1 mlkg (age gt 8 year)

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Seizure Precautions

Care around water

Heights

No motorized vehicles

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Take home points

Reconsider ldquofullrdquo workup for complex

febrile seizures

Early initiation of anti-epileptic drugs

Benzodiazepines are first line

Phenobarbital for neonates

Vitamin ldquoKrdquo

Check glucose early and often

lecturesumemorgAAEM

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

TRAUMA

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Age RR

Infant 30-60

Toddler 24-40

Preschooler 22-34

School-aged 18-30

Adolescent 12-16

gt 60

gt30

gt15

Pearls

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Circulation

Heart rate

Pulse quality

Capillary refill time

Skin temperature

Blood pressure

([2 x age] + 70)

[2 x age] + 90

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

[2 x age] + 90

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

abdominal tenderness

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Abdominal trauma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Low risk

Ann Emerg Med 2012

Prospective observational cohort

20 EDs

Prediction rule to identify children with blunt

torso trauma at very low risk of intraabdominal

injuries requiring acute intervention

12044 children

761 (63) with intra-abdominal injuries

203 (267) received acute interventions

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Blunt abdominal injuries

Prediction rule

No evidence of abdominal wall trauma or seat

belt sign

Glasgow Coma Scale score gt13

No abdominal tenderness

No evidence of thoracic wall trauma

No complaints of abdominal pain

No decreased breath sounds and

No vomiting

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Blunt abdominal injuries

Results

NPV 999

Sensitivity 97

Specificity 425

Missed 65028 (01) with IAI

5 had lab abnormalities

All had hemoperitoneum

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Holmes et al Ann Emerg Med 2012

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Fig 3 Suggested algorithm for evaluation of children with blunt torso trauma IAI ntra-abdominal injury

Holmes et al Ann Emerg Med 2002

Labs

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Case

8 yo male involved in MVC

VS 374 HR 96 RR 18 BP 11085 97

Exam well-appearing no complaints

Abdominal tenderness elevated LFTs

CT scan negative

Dispo

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Blunt abdominal injuries

Conclusion

A prediction rule consisting of 7 patient history and physical examination findings and without laboratory or ultrasonographic information identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention

CT scan rarely misses clinically important blunt abdominal traumatic injuries

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Cervical spine

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Plain films for cervical spine

Nigrovic et al Pediatr Emerg Care 2012

PECARN

30x radiation CT vs plain films

Retrospective cohort

90 sensitivity for CSI (2+ views)

Higher for older children

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Cervical spine imaging

0 with normal neuro exam had missed

injuries requiring neurosurgical

intervention

Higher risk with normal radiographs

AMS

Intubation

Focal neuro deficit

Congenital cervical spine abnormality

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Cervical spine imaging

Conclusion

Two-view plain radiographs had high

sensitivity (90) for cervical spine injury

in pediatric patients

High risk patients may warrant advanced

imaging

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Head Injury

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

LOC

Vomited

15 mo

HR 130 RR 26 BP 7540 97

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Kupperman et al Lancet 2009

Age lt 2 years

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Kupperman et al Lancet 2009

Age ge 2 years

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Case

8 yo male head injury

VS HR 96 RR 18 BP 11085 97

Exam awake alert

Ondansetron

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Ondansetron

Sturm et al AJEM 2013

Retrospective cross-sectional study

Lower likelihood of 72 hour return

Use no effect on admission or returns

Rx no effect on returns or readmissions

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Ondansetron and head injury

Conclusion

Ondansetron did not mask symptoms and

decreased return visits to ED in children

who underwent CT and were discharged

home

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Image gently

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

One exceptionhellip

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Skeletal survey in abuse

Duffy et al Pediatrics 2011

2006 gt14000 child victims

703 consecutive patients

Retrospective descriptive study

Use of skeletal survey (SS) to identify children

most likely to have unsuspected fractures

How often SS results directly influence

diagnosis of abuse

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Skeletal survey in abuse

Positive SS result = previously unsuspected

fracture

703 SS 108 positive results

79 had gt1 healing fracture

Highest rates

lt 6 months

ALTE or seizure

Suspected abusive head trauma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Skeletal survey in abuse

Conclusion

Almost 11 of SS positive

In 50 positive SS cases results directly

influenced the decision to make the

diagnosis of abuse

Obtain SS in infants lt6 months with

suspected abuse

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Take home points

Image gently

Clinical decision rules

LFTs for blunt abdominal trauma

If imaging negative ondansetron okay

If imaging negative safe to discharge

Be vigilant about NAT

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Summary so far

Seizures

Limited workup for complex febrile seizures

Know agents for status epilepticus

Trauma

Clinical decision rules (plus labs)

Image gently

Consider NAT

lecturesumemorgAAEM

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Respiratory

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 130 RR 26 BP 7540 94

Exam smiling wheezing mild retractions

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Skjerven et al NEJM 2013

Eight center randomized double-blind trial

404 infants

Conclusion

Inhaled racemic adrenaline is not more effective than inhaled saline

The strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Case

15 month male with 3 day cough

congestion rhinorrhea

VS T 384 HR 150 RR 50 BP 7540 90

Exam wheezing mod retractions

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

High Flow Nasal Cannula

Wing et al Pediatr Emerg Care 2012

Retrospective

PED to PICU with ARI over 4 years

848 patients in 3 cohorts

228 HFNC

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Results

HFNC success rates

84 - 88

Decreased intubation rate

Decreased ventilator utilization by 50

No difference PICU LOS mortality or

mean duration of mechanical ventilation

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

HFNC

Conclusion

HFNC decreased need for intubation and

mechanical ventilator utilization for

children in the PED admitted to PICU

with ARI particularly when initiated early

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

HFNC ndash predicting intubation

Kelly et al Pediatr Emerg Care 2013

Retrospective review

Age lt 2 years

All causes respiratory distress

Predictors of success failure

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

HFNC ndash predicting intubation

Conclusions

Predictive of failure

triage RR gt 90th percentile for age

initial venous PCO2 gt 50 mm Hg

initial venous pH lt 730

Diagnosis of acute bronchiolitis was

protective with respect to intubation

following HFNC

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Heliox for bronchiolitis

Chowdhury et al Pediatrics 2013

Bronchiolitis Randomized Controlled Trial

Emergency-Assisted Therapy with

HelioxmdashAn Evaluation (BREATHE)

largest multicenter randomized

controlled trial investigating efficacy of

Heliox in acute bronchiolitis

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Heliox for bronchiolitis

Conclusion

Heliox therapy does not reduce length of

treatment unless given via a tightfitting

facemask or CPAP

Nasal cannula heliox therapy is ineffective

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Corticosteroid timing and length of stay for children with

asthma in the Emergency Department

Davis SR Burke G Hogan E Smith SR

Asthma

Asthma and steroids

Conclusion

Early steroid administration decreases time to

clinical improvement and discharge and reduced

admission rates in children presenting with

moderate to severe acute asthma

exacerbations

Steroids in asthma

Dexamethasone vs prednisone

Keeney et al Pediatrics 2014

Redman Arch Dis Children 2013

Williams et al Clin Pediatr 2013

Steroids in asthma

Conclusions (dexamethasone)

Equal efficacy

Shorter duration of treatment

Less vomiting

Improved compliance

Parental preference

Take home points

Racemic epi as effective as inhaled saline

Consider high flow nasal cannula in

patients with respiratory distress

Check the mask fit with heliox

Give steroids early for asthma

Dexamethasone gt prednisone

lecturesumemorgAAEM

Summary so far

Seizures Limited work-up for CFS

Addition of vitamin ldquoKrdquo for status

Trauma Image gently

Consider NAT

Respiratory High flow nasal cannula decreases intubation

Early administration of steroids

lecturesumemorgAAEM

Bonus

Withdrawl of OTC CCM

Alternatives

Fluids

Humidified air

NSAIDS

Anti-histamines

Echinacea

Zinc

Honey

Vitamin C

25 mL qhs (gt1 year of age)

Summary

Complex febrile seizures do not warrant

extensive diagnostic or imaging studies

Consider vitamin ldquoKrdquo for status epilepticus

Clinical decision rules for trauma

LFTs for blunt intraabdominal injury

Ondansetron for head injury safe

Early steroids for asthma

High flow nasal cannula decreases need for

intubation

lecturesumemorgAAEM

Special thanks

Amal Mattu and Ghazala Sharieff

Questions

mluumarylandedu

For a PDF copy of all slides go to

lecturesumemorgAAEM [will be posted after AAEM for 1 month]

Steroids in asthma

Dexamethasone vs prednisone

Keeney et al Pediatrics 2014

Redman Arch Dis Children 2013

Williams et al Clin Pediatr 2013

Steroids in asthma

Conclusions (dexamethasone)

Equal efficacy

Shorter duration of treatment

Less vomiting

Improved compliance

Parental preference

Take home points

Racemic epi as effective as inhaled saline

Consider high flow nasal cannula in

patients with respiratory distress

Check the mask fit with heliox

Give steroids early for asthma

Dexamethasone gt prednisone

lecturesumemorgAAEM

Summary so far

Seizures Limited work-up for CFS

Addition of vitamin ldquoKrdquo for status

Trauma Image gently

Consider NAT

Respiratory High flow nasal cannula decreases intubation

Early administration of steroids

lecturesumemorgAAEM

Bonus

Withdrawl of OTC CCM

Alternatives

Fluids

Humidified air

NSAIDS

Anti-histamines

Echinacea

Zinc

Honey

Vitamin C

25 mL qhs (gt1 year of age)

Summary

Complex febrile seizures do not warrant

extensive diagnostic or imaging studies

Consider vitamin ldquoKrdquo for status epilepticus

Clinical decision rules for trauma

LFTs for blunt intraabdominal injury

Ondansetron for head injury safe

Early steroids for asthma

High flow nasal cannula decreases need for

intubation

lecturesumemorgAAEM

Special thanks

Amal Mattu and Ghazala Sharieff

Questions

mluumarylandedu

For a PDF copy of all slides go to

lecturesumemorgAAEM [will be posted after AAEM for 1 month]

Steroids in asthma

Conclusions (dexamethasone)

Equal efficacy

Shorter duration of treatment

Less vomiting

Improved compliance

Parental preference

Take home points

Racemic epi as effective as inhaled saline

Consider high flow nasal cannula in

patients with respiratory distress

Check the mask fit with heliox

Give steroids early for asthma

Dexamethasone gt prednisone

lecturesumemorgAAEM

Summary so far

Seizures Limited work-up for CFS

Addition of vitamin ldquoKrdquo for status

Trauma Image gently

Consider NAT

Respiratory High flow nasal cannula decreases intubation

Early administration of steroids

lecturesumemorgAAEM

Bonus

Withdrawl of OTC CCM

Alternatives

Fluids

Humidified air

NSAIDS

Anti-histamines

Echinacea

Zinc

Honey

Vitamin C

25 mL qhs (gt1 year of age)

Summary

Complex febrile seizures do not warrant

extensive diagnostic or imaging studies

Consider vitamin ldquoKrdquo for status epilepticus

Clinical decision rules for trauma

LFTs for blunt intraabdominal injury

Ondansetron for head injury safe

Early steroids for asthma

High flow nasal cannula decreases need for

intubation

lecturesumemorgAAEM

Special thanks

Amal Mattu and Ghazala Sharieff

Questions

mluumarylandedu

For a PDF copy of all slides go to

lecturesumemorgAAEM [will be posted after AAEM for 1 month]

Take home points

Racemic epi as effective as inhaled saline

Consider high flow nasal cannula in

patients with respiratory distress

Check the mask fit with heliox

Give steroids early for asthma

Dexamethasone gt prednisone

lecturesumemorgAAEM

Summary so far

Seizures Limited work-up for CFS

Addition of vitamin ldquoKrdquo for status

Trauma Image gently

Consider NAT

Respiratory High flow nasal cannula decreases intubation

Early administration of steroids

lecturesumemorgAAEM

Bonus

Withdrawl of OTC CCM

Alternatives

Fluids

Humidified air

NSAIDS

Anti-histamines

Echinacea

Zinc

Honey

Vitamin C

25 mL qhs (gt1 year of age)

Summary

Complex febrile seizures do not warrant

extensive diagnostic or imaging studies

Consider vitamin ldquoKrdquo for status epilepticus

Clinical decision rules for trauma

LFTs for blunt intraabdominal injury

Ondansetron for head injury safe

Early steroids for asthma

High flow nasal cannula decreases need for

intubation

lecturesumemorgAAEM

Special thanks

Amal Mattu and Ghazala Sharieff

Questions

mluumarylandedu

For a PDF copy of all slides go to

lecturesumemorgAAEM [will be posted after AAEM for 1 month]

Summary so far

Seizures Limited work-up for CFS

Addition of vitamin ldquoKrdquo for status

Trauma Image gently

Consider NAT

Respiratory High flow nasal cannula decreases intubation

Early administration of steroids

lecturesumemorgAAEM

Bonus

Withdrawl of OTC CCM

Alternatives

Fluids

Humidified air

NSAIDS

Anti-histamines

Echinacea

Zinc

Honey

Vitamin C

25 mL qhs (gt1 year of age)

Summary

Complex febrile seizures do not warrant

extensive diagnostic or imaging studies

Consider vitamin ldquoKrdquo for status epilepticus

Clinical decision rules for trauma

LFTs for blunt intraabdominal injury

Ondansetron for head injury safe

Early steroids for asthma

High flow nasal cannula decreases need for

intubation

lecturesumemorgAAEM

Special thanks

Amal Mattu and Ghazala Sharieff

Questions

mluumarylandedu

For a PDF copy of all slides go to

lecturesumemorgAAEM [will be posted after AAEM for 1 month]

Bonus

Withdrawl of OTC CCM

Alternatives

Fluids

Humidified air

NSAIDS

Anti-histamines

Echinacea

Zinc

Honey

Vitamin C

25 mL qhs (gt1 year of age)

Summary

Complex febrile seizures do not warrant

extensive diagnostic or imaging studies

Consider vitamin ldquoKrdquo for status epilepticus

Clinical decision rules for trauma

LFTs for blunt intraabdominal injury

Ondansetron for head injury safe

Early steroids for asthma

High flow nasal cannula decreases need for

intubation

lecturesumemorgAAEM

Special thanks

Amal Mattu and Ghazala Sharieff

Questions

mluumarylandedu

For a PDF copy of all slides go to

lecturesumemorgAAEM [will be posted after AAEM for 1 month]

Withdrawl of OTC CCM

Alternatives

Fluids

Humidified air

NSAIDS

Anti-histamines

Echinacea

Zinc

Honey

Vitamin C

25 mL qhs (gt1 year of age)

Summary

Complex febrile seizures do not warrant

extensive diagnostic or imaging studies

Consider vitamin ldquoKrdquo for status epilepticus

Clinical decision rules for trauma

LFTs for blunt intraabdominal injury

Ondansetron for head injury safe

Early steroids for asthma

High flow nasal cannula decreases need for

intubation

lecturesumemorgAAEM

Special thanks

Amal Mattu and Ghazala Sharieff

Questions

mluumarylandedu

For a PDF copy of all slides go to

lecturesumemorgAAEM [will be posted after AAEM for 1 month]

Summary

Complex febrile seizures do not warrant

extensive diagnostic or imaging studies

Consider vitamin ldquoKrdquo for status epilepticus

Clinical decision rules for trauma

LFTs for blunt intraabdominal injury

Ondansetron for head injury safe

Early steroids for asthma

High flow nasal cannula decreases need for

intubation

lecturesumemorgAAEM

Special thanks

Amal Mattu and Ghazala Sharieff

Questions

mluumarylandedu

For a PDF copy of all slides go to

lecturesumemorgAAEM [will be posted after AAEM for 1 month]

Special thanks

Amal Mattu and Ghazala Sharieff

Questions

mluumarylandedu

For a PDF copy of all slides go to

lecturesumemorgAAEM [will be posted after AAEM for 1 month]

Questions

mluumarylandedu

For a PDF copy of all slides go to

lecturesumemorgAAEM [will be posted after AAEM for 1 month]