Important PEM Articles: The Year in Review Eric Hoppa, MD Attending Physician Pediatric Emergency Medicine Pediatric Emergency Medicine Cohen Children’s

Important PEM Important PEM Articles:Articles:

The Year in The Year in ReviewReviewEric Hoppa, MDEric Hoppa, MD

Attending PhysicianAttending Physician Pediatric Emergency MedicinePediatric Emergency Medicine

Cohen Children’s Medical CenterCohen Children’s Medical Center

Goals & ObjectivesGoals & Objectives

Not journal clubNot journal club Review six articles from the last 12 Review six articles from the last 12

months relevant to care in pediatric months relevant to care in pediatric EDED

Allow you to apply evidence based Allow you to apply evidence based medicine to the care of common medicine to the care of common pediatric problemspediatric problems

Clinical Scenario # 1Clinical Scenario # 1

A 6 week old female presents to the A 6 week old female presents to the ED with one day of fever to 102 ED with one day of fever to 102 without additional symptoms.without additional symptoms.

Urinalysis has > 50 WBCs and is Urinalysis has > 50 WBCs and is nitrite positivenitrite positive

Parents want to know how long they Parents want to know how long they will stay in the hospital? Can they will stay in the hospital? Can they be managed as an outpatient? be managed as an outpatient?

Febrile Infants with Febrile Infants with Urinary Tract Infections Urinary Tract Infections

at Very Low Risk for at Very Low Risk for Adverse Effects and Adverse Effects and

BacteremiaBacteremiaSchnadower D, Kuppermann N, Macias CG, Freedman SB, Schnadower D, Kuppermann N, Macias CG, Freedman SB, Baskin MN, Ishimine P, Scribner C, Okada P, Beach H, Baskin MN, Ishimine P, Scribner C, Okada P, Beach H, Bulloch B, Agrawal D, Saunders M, Sutherland DM, Bulloch B, Agrawal D, Saunders M, Sutherland DM,

Blackstone MM, Sarnaik A, McManemy J, Brent A, Bennett Blackstone MM, Sarnaik A, McManemy J, Brent A, Bennett J, Plymale JM, Solari P, Mann DJ, Dayan PS; American J, Plymale JM, Solari P, Mann DJ, Dayan PS; American Academy of Pediatrics Pediatric Emergency Medicine Academy of Pediatrics Pediatric Emergency Medicine Collaborative Research Committee. Collaborative Research Committee. Pediatrics.Pediatrics. 2010 2010

Dec;126(6):1074-83.Dec;126(6):1074-83.

Infants with UTIInfants with UTI

Goals Goals Management of febrile UTI in patients Management of febrile UTI in patients

29-60 days of age29-60 days of age Develop a clinical prediction model of Develop a clinical prediction model of

patients at low risk of patients at low risk of bacteremia/adverse eventsbacteremia/adverse events


MethodsMethods Retrospective review (20 centers)Retrospective review (20 centers) Fever Fever ≥ ≥ 3838° & UTI (> 50,000 cfu or ° & UTI (> 50,000 cfu or

10,000 w/ + UA)10,000 w/ + UA) OutcomesOutcomes

BacteremiaBacteremia Adverse EventsAdverse Events

Death, shock, bacterial meningitis, ICU admit, Death, shock, bacterial meningitis, ICU admit, mechanical ventilation, othermechanical ventilation, other


1895 febrile infants with UTI

176 discharged home from ED (9.3%)

1719 hospitalized(90.7%)

Adverse events 0/146Bacteremia 6/176 (3.4%)

Adverse events 51/1696 (3.0%)Bacteremia 117/1701 (6.9%)


ResultsResults Recursive partitioning for adverse events (AE)Recursive partitioning for adverse events (AE)

Clinically ill in EDClinically ill in ED High risk medical history (previous SBI or eval for High risk medical history (previous SBI or eval for

SBI, GU abnormality, <37WGA, or severe systemic SBI, GU abnormality, <37WGA, or severe systemic disease)disease)

No No predictor present – predictor present – 1/1206 (0.08%) AE1/1206 (0.08%) AE Any Any predictor present – predictor present – 50/636 (7.9%) AE 50/636 (7.9%) AE

Sensitivity 98.0% Sensitivity 98.0% Specificity 67.3%Specificity 67.3% NPV 99.9% NPV 99.9% PPV 7.9%PPV 7.9%


ResultsResults Recursive partitioning for bacteremiaRecursive partitioning for bacteremia

Clinically illClinically ill High risk PMHHigh risk PMH ANC < 1500 or bands > 1250ANC < 1500 or bands > 1250 No No predictor present – predictor present – 28/862 (3.2%) 28/862 (3.2%)

bacteremiabacteremia Any Any predictor present – predictor present – 95/1015 (9.4%) 95/1015 (9.4%)

bacteremiabacteremia

Sensitivity 77.2% Sensitivity 77.2% Specificity 47.6%Specificity 47.6% NPV 96.8% NPV 96.8% PPV 9.4%PPV 9.4%


Take home pointsTake home points Accurately predict infants with UTI at Accurately predict infants with UTI at

low risk of developing adverse eventslow risk of developing adverse events Consider short hospitalization (24hrs) Consider short hospitalization (24hrs)

or 1 time dose of ceftriaxone with close or 1 time dose of ceftriaxone with close f/uf/u

3.2% rate of bacteremia if clinically well 3.2% rate of bacteremia if clinically well and no high risk medical historyand no high risk medical history

Limited by retrospective natureLimited by retrospective nature

Clinical Scenario # 2Clinical Scenario # 2 A 12 year-old male presents with an A 12 year-old male presents with an

angulated distal radius and ulna fracture angulated distal radius and ulna fracture that will require procedural sedation for that will require procedural sedation for reduction.reduction.

Your brand new first year fellow is eager Your brand new first year fellow is eager to perform her first ketamine procedural to perform her first ketamine procedural sedation….sedation….

…….But she is worried about causing .But she is worried about causing laryngospasm. She asks you if there is laryngospasm. She asks you if there is anyway to predict which children will anyway to predict which children will have laryngospasm?have laryngospasm?

Laryngospasm During Laryngospasm During Emergency Department Emergency Department

Ketamine SedationKetamine SedationA Case-Control StudyA Case-Control Study

Green SM, Roback MG, Krauss B for Green SM, Roback MG, Krauss B for the Emergency Department Ketamine the Emergency Department Ketamine Meta-analysis Study Group. Meta-analysis Study Group. Pediatr Pediatr

Emerg CareEmerg Care, 2010 Nov;26(11):798-802., 2010 Nov;26(11):798-802.

Ketamine & Ketamine & LaryngospasmLaryngospasm

MethodsMethods Case controlled analysis of 8282 Case controlled analysis of 8282

ketamine sedations from 32 previous ketamine sedations from 32 previous studiesstudies

22 episodes of laryngospasm matched 22 episodes of laryngospasm matched to 4 controls from same studyto 4 controls from same study


MethodsMethods Matched by 5 dichotomous variablesMatched by 5 dichotomous variables

ASA status ≥ 3ASA status ≥ 3 Oropharyngeal procedureOropharyngeal procedure IV vs IM administrationIV vs IM administration Anticholingergic givenAnticholingergic given Benzodiazepine givenBenzodiazepine given

Controls matched to variables except Controls matched to variables except for variable studied in individual casefor variable studied in individual case


ResultsResults Incidence of laryngospasm 0.3%Incidence of laryngospasm 0.3% Comparison and controls were equally Comparison and controls were equally

matched across all variablesmatched across all variables

Ketamine & LaryngospasmKetamine & LaryngospasmMultivariate Analysis – Risk of Multivariate Analysis – Risk of

LaryngospasmLaryngospasm No increased riskNo increased risk

AgeAge Age < 2Age < 2 Total doseTotal dose High IV doseHigh IV dose Oropharyngeal Oropharyngeal

procedureprocedure ASA ≥ 3ASA ≥ 3 IV vs IM routeIV vs IM route Anticholinergic Anticholinergic

givengiven

Increased risk Increased risk Benzodiazepine Benzodiazepine

givengiven


Take home points:Take home points: Largest analysis of ketamine associated Largest analysis of ketamine associated

laryngospasmlaryngospasm No evidence of association of No evidence of association of

laryngospasm w/ age, dose, or other laryngospasm w/ age, dose, or other clinical factors (except co-administration clinical factors (except co-administration of benzodiazapines)of benzodiazapines)

Laryngospasm is likely idiosyncraticLaryngospasm is likely idiosyncratic Administration of anti-cholinergics Administration of anti-cholinergics

unnecessaryunnecessary


The previous patient undergoes successful The previous patient undergoes successful closed reduction of his fracture by closed reduction of his fracture by orthopedics.orthopedics.

He is discharged home without complications.He is discharged home without complications. After discharge his nurse apologizes that she After discharge his nurse apologizes that she

was unable to place an IV and give IV was unable to place an IV and give IV narcotics prior to the patient’s initial x-ray.narcotics prior to the patient’s initial x-ray.

She wonders aloud that there must be a She wonders aloud that there must be a quicker alternative to IV narcotics in this quicker alternative to IV narcotics in this situation.situation.

Use of Intranasal Fentanyl Use of Intranasal Fentanyl for the Relief of Pediatric for the Relief of Pediatric Orthopedic Trauma PainOrthopedic Trauma Pain

Saunders M, Adelgais K, Nelson D. Saunders M, Adelgais K, Nelson D. Acad Emerg Med. Acad Emerg Med. 2010 2010

Nov;17(11):1155-61.Nov;17(11):1155-61.

Intranasal FentanylIntranasal Fentanyl

BackgroundBackground Intranasal fentanyl is safe and Intranasal fentanyl is safe and

efficaciousefficacious First study to assess a single dose in the First study to assess a single dose in the

treatment of pain from orthopedic treatment of pain from orthopedic traumatrauma


MethodsMethods Prospective, non-blinded, convenience Prospective, non-blinded, convenience

samplesample Age 3-18 years with suspected fracture and Age 3-18 years with suspected fracture and

moderate to severe painmoderate to severe pain Either WBS or VAS scale used to assess Either WBS or VAS scale used to assess

painpain Given 2Given 2µg/kg intranasal fentanyl (max 100 µg/kg intranasal fentanyl (max 100

µg) µg) Pain reassessed at 10, 20, and 30 minutesPain reassessed at 10, 20, and 30 minutes


ResultsResults 81 patients enrolled81 patients enrolled

53 patients in WBS group53 patients in WBS group 28 patients in VAS group28 patients in VAS group Mean age 8 yearsMean age 8 years Most common fractures – forearm, Most common fractures – forearm,

supracondylar, and claviclesupracondylar, and clavicle No adverse outcomesNo adverse outcomes


GroupGroup BaselinBaseline Paine Pain

10 10 MinuteMinute

ss

20 20 MinuteMinute

ss

30 30 MinuteMinute

ss

WBSWBS

(faces)(faces)55 33 22 22

VASVAS

(mm)(mm)7070 4949 4545 4343

WBS = Wong Baker Face Scale VAS = Visual Analog Scale

Decrease in Pain over Time


GroupGroup Time 10Time 10

(%)(%)Time 20Time 20

(%)(%)Time 30Time 30

(%)(%)

WBSWBS 7474 7474 8787

VASVAS 6868 6464 6161

TotalTotal 7272 7070 7878

WBS = Wong Baker Face Scale VAS = Visual Analog Scale

Patients with Significant Decrease in Pain over First 30 Minutes


Take home points:Take home points: Single dose intranasal fentanyl (2Single dose intranasal fentanyl (2µg/kg) µg/kg)

provides significant improvement in provides significant improvement in patient pain patient pain

Pain relief is sustainable Pain relief is sustainable Greater improvement in younger Greater improvement in younger

patientspatients Dosing is safeDosing is safe


A 7 year-old male with a history of A 7 year-old male with a history of seizure disorder arrives to the ED in seizure disorder arrives to the ED in status epilepticus.status epilepticus.

Multiple attempts at IV access are Multiple attempts at IV access are unsuccessful.unsuccessful.

The nurse asks you if she should The nurse asks you if she should give the patient rectal diazepam or if give the patient rectal diazepam or if there is another option for this there is another option for this patient?patient?

Midazolam Versus Midazolam Versus Diazepam for theDiazepam for the

Treatment of Status Treatment of Status Epilepticus in Children Epilepticus in Children and Young Adults: A and Young Adults: A

Meta-analysisMeta-analysisMcMullan J, Sasson C, Pancioli A, McMullan J, Sasson C, Pancioli A,

Sibergleit R. Sibergleit R. Acad Emerg Med. Acad Emerg Med. 2010 2010 June;17(6):575-81.June;17(6):575-81.

Midazolam vs DiazepamMidazolam vs Diazepam

MethodsMethods Meta-analysis of non-IV midazolam vs Meta-analysis of non-IV midazolam vs

diazepam (via any route) for treatment diazepam (via any route) for treatment of status epilepticus of status epilepticus Time to cessation of seizureTime to cessation of seizure Respiratory complicationsRespiratory complications


ResultsResults 6 studies including 774 patients6 studies including 774 patients

One study IV diazepam vs IM midazolamOne study IV diazepam vs IM midazolam Two studies IV diazepam vs intranasal Two studies IV diazepam vs intranasal

midazolammidazolam Three studies PR diazepam vs buccal Three studies PR diazepam vs buccal

midazolammidazolam


ResultsResults Midazolam (via any route)Midazolam (via any route) stopped stopped

seizure soonerseizure sooner RR 1.52 (1.27-1.82)RR 1.52 (1.27-1.82) Buccal midazolamBuccal midazolam improvedimproved seizure seizure

cessation compared to rectal diazepamcessation compared to rectal diazepam RR 1.54 (1.29-1.85)RR 1.54 (1.29-1.85)

MidazolamMidazolam given 2.46 minutes (1.52-given 2.46 minutes (1.52-3.39) quicker than diazepam3.39) quicker than diazepam

Similar respiratory complicationsSimilar respiratory complications


Take home pointsTake home points Data supports the use of non-IV (IM, IN, Data supports the use of non-IV (IM, IN,

buccal) midazolam when compared with buccal) midazolam when compared with diazepamdiazepam

Future replacement of rectal diazepam Future replacement of rectal diazepam with IN or buccal midazolamwith IN or buccal midazolam

Need for comparison with lorazepamNeed for comparison with lorazepam


A 3 year-old female presents to the ED with a A 3 year-old female presents to the ED with a one week history of enlarging buttock one week history of enlarging buttock abscess. abscess.

You perform an incision and drainage and You perform an incision and drainage and prescribe outpatient antibiotics.prescribe outpatient antibiotics.

The “know it all” 3The “know it all” 3rdrd year medical student year medical student tells you he has read numerous studies in tells you he has read numerous studies in adults that say you do not need to prescribe adults that say you do not need to prescribe antibiotics after I&D of simple abscesses. He antibiotics after I&D of simple abscesses. He asks why you do not follow this literature in asks why you do not follow this literature in children? children?

Randomized, Controlled Randomized, Controlled Trial of Antibiotics in the Trial of Antibiotics in the

Management of Management of Community-Acquired Skin Community-Acquired Skin Abscesses in the Pediatric Abscesses in the Pediatric

PatientPatientDuong M, Markwell S, Peter J, Duong M, Markwell S, Peter J,

Barenkamp S. Barenkamp S. Annals Emerg Med. Annals Emerg Med. 2010 May;55(5):401-7.2010 May;55(5):401-7.

Abscess and AntibioticsAbscess and Antibiotics

First pediatric RCT assessing need for First pediatric RCT assessing need for antibiotics in the care of skin antibiotics in the care of skin abscessesabscesses

MethodsMethods Double blinded RCTDouble blinded RCT I&D followed by placebo vs trimethoprim-I&D followed by placebo vs trimethoprim-

sulfamethoxazole (10 day course)sulfamethoxazole (10 day course) Follow-up at 10-14 days and 90 daysFollow-up at 10-14 days and 90 days Primary outcome: Treatment failure at Primary outcome: Treatment failure at

10 days10 days


Inclusion criteriaInclusion criteria Age 3-18 yearsAge 3-18 years Non-toxic and temp Non-toxic and temp ≤ 38.4°≤ 38.4° Abscess (clinical and/or bedside Abscess (clinical and/or bedside

ultrasound)ultrasound) Acute onset < 1 weekAcute onset < 1 week FluctuanceFluctuance ErythemaErythema IndurationInduration TendernessTenderness ± Drainage± Drainage


ResultsResults 161 patients enrolled, 149 completed 161 patients enrolled, 149 completed

trial (12 lost to follow-up)trial (12 lost to follow-up) Median age 4 years Median age 4 years 80% CA-MRSA80% CA-MRSA

18% clindamycin resistance18% clindamycin resistance All sensitive to trimethoprim-All sensitive to trimethoprim-

sulfamethoxazole and vancomycinsulfamethoxazole and vancomycin


ResultsResults Failure rate at 10 day follow-upFailure rate at 10 day follow-up

Placebo group 4/76 (5.3%)Placebo group 4/76 (5.3%) Antibiotic group 3/73 (4.1%)Antibiotic group 3/73 (4.1%)

New lesions at 10 day follow-upNew lesions at 10 day follow-up Placebo 19/76 (26.4%)Placebo 19/76 (26.4%) Antibiotic 9/73 (12.3%)Antibiotic 9/73 (12.3%)

New lesions at 90 day follow-upNew lesions at 90 day follow-up Placebo 15/52 (28.8%)Placebo 15/52 (28.8%) Antibiotic 13/46 (28.3%)Antibiotic 13/46 (28.3%)


Take home pointsTake home points Oral antibiotics not necessary for Oral antibiotics not necessary for

resolution of a simple skin abscess resolution of a simple skin abscess following I&Dfollowing I&D

Antibiotics may help decrease new skin Antibiotics may help decrease new skin lesions in the short-term, but do not lesions in the short-term, but do not affect incidence of abscess recurrenceaffect incidence of abscess recurrence

Unclear whether antibiotics are Unclear whether antibiotics are necessary for abscesses with surrounding necessary for abscesses with surrounding cellulitis or multiple abscessescellulitis or multiple abscesses


A 9 year-old male arrives to the ED in A 9 year-old male arrives to the ED in cardiac arrest after collapsing while cardiac arrest after collapsing while playing soccer.playing soccer.

You resuscitate the patient and transfer You resuscitate the patient and transfer him to the PICU.him to the PICU.

The same medical student asks you why The same medical student asks you why the bystanders at the soccer game did the bystanders at the soccer game did conventional CPR when adult studies and conventional CPR when adult studies and the new PALS guidelines say you can do the new PALS guidelines say you can do chest compression only CPR?chest compression only CPR?

Conventional and Chest-Conventional and Chest-compression-only compression-only

Cardiopulmonary Resuscitation Cardiopulmonary Resuscitation by Bystanders for Children who by Bystanders for Children who

have out-of-hospital Cardiac have out-of-hospital Cardiac Arrests: A Prospective, Arrests: A Prospective,

Nationwide, Population-Based Nationwide, Population-Based Cohort StudyCohort StudyKitamura T, Iwami T, Kawamura T, Kitamura T, Iwami T, Kawamura T,

Nagau K, Tanaka H, Nadkarni V, Berg Nagau K, Tanaka H, Nadkarni V, Berg RA, Hiraide A. RA, Hiraide A. Lancet. Lancet. 2010 Apr 2010 Apr

17;375(9723):1347-54.17;375(9723):1347-54.

CPRCPR

Compression only CPR recommended Compression only CPR recommended for adults, but not childrenfor adults, but not children

MethodsMethods Nationwide, prospective, observational Nationwide, prospective, observational

study of children with out of hospital study of children with out of hospital cardiac arrest (2 year period)cardiac arrest (2 year period)

Age of patient and presence and type of Age of patient and presence and type of bystander CPRbystander CPR

Endpoint: Favorable neurologic Endpoint: Favorable neurologic outcome 1 month after arrestoutcome 1 month after arrest

CPRCPR

ResultsResults 5170 children included in analysis5170 children included in analysis

Non-cardiac 3664 (71%)Non-cardiac 3664 (71%) Cardiac 1494 (29%)Cardiac 1494 (29%)

2439 children received bystander CPR 2439 children received bystander CPR (47%)(47%) 1551 standard CPR (30%)1551 standard CPR (30%) 888 chest-compression-only CPR (17%)888 chest-compression-only CPR (17%)

CPRCPR

ResultsResults Associated with improved neurologic Associated with improved neurologic

outcomesoutcomes Any bystander CPR 4.5% vs 1.9%Any bystander CPR 4.5% vs 1.9% Age > 1 year 4.1 vs 1.7%Age > 1 year 4.1 vs 1.7% Witnessed arrest 6.7-10.3% vs 1.3%Witnessed arrest 6.7-10.3% vs 1.3% VF as first documented rhythm 20.6% vs VF as first documented rhythm 20.6% vs

2.3%2.3%

CPRCPRNo CPRNo CPR Bystander Bystander

CPRCPRConventionConvention

alalCompressiCompressi

onon

Non-CardiacNon-Cardiac

Age 1-17Age 1-17

1 month 1 month survivalsurvival

6.9%6.9% 13.2%13.2% 15.9%15.9% 8.9%8.9%

Favorable Favorable neuro neuro outcomeoutcome

1.5%1.5% 5.1%5.1% 7.2%7.2% 1.6%1.6%

Age < 1Age < 1


7.8%7.8% 7.8%7.8% 7.8%7.8% 7.9%7.9%


2.0%2.0% 2.0%2.0% 0.9%0.9% 2.6%2.6%

CPRCPRNo No

CPRCPRBystandeBystande

r CPRr CPRConventionConvention

alalCompressioCompressio

nn

CardiacCardiac

Age 1-17Age 1-17


10.6%10.6% 16.1%16.1% 16.5%16.5% 16.0%16.0%


4.1%4.1% 9.5%9.5% 8.9%8.9% 9.9%9.9%

Age < 1Age < 1


4.6%4.6% 6.4%6.4% 5.3%5.3% 7.0%7.0%


1.4%1.4% 1.2%1.2% 0.8%0.8% 1.4%1.4%

CPRCPR

Take home pointsTake home points Any CPR is better than no CPRAny CPR is better than no CPR Compression only CPR is equivalent to Compression only CPR is equivalent to

conventional CPR for arrests from conventional CPR for arrests from cardiac causescardiac causes

In arrests from non-cardiac causes In arrests from non-cardiac causes conventional CPR improves outcome conventional CPR improves outcome compared with compression only CPRcompared with compression only CPR

Final Thoughts….Final Thoughts….

Infants with UTI may be safely Infants with UTI may be safely treated with short course of IV treated with short course of IV antibioticsantibiotics

Laryngospasm associated with Laryngospasm associated with ketamine is likely an idiosynchratic ketamine is likely an idiosynchratic eventevent

Intranasal fentanyl can be used Intranasal fentanyl can be used safely and effectively to reduce pain safely and effectively to reduce pain in children with suspected fracturesin children with suspected fractures

Final Thoughts….Final Thoughts….

Midazolam by any route is superior Midazolam by any route is superior to rectal or IV diazepam in the to rectal or IV diazepam in the treatment of status epilepticustreatment of status epilepticus

Simple abscesses can be treated Simple abscesses can be treated successfully with incision and successfully with incision and drainage alonedrainage alone

Bystander conventional CPR is Bystander conventional CPR is superior to compression only CPR in superior to compression only CPR in pediatric out of hospital arrestspediatric out of hospital arrests

Looking Ahead….Looking Ahead….

PECARN review of factors PECARN review of factors associated with c-spine injuriesassociated with c-spine injuries

Comparison of ketamine with Comparison of ketamine with propofol to ketamine alone for propofol to ketamine alone for procedural sedationprocedural sedation

Thank YouThank You

Documents

Important PEM Articles: The Year in Review Eric Hoppa, MD Attending Physician Pediatric Emergency Medicine Pediatric Emergency Medicine Cohen Children’s