Risk Management Pitfalls in the Management of Pediatric Stroke January 21, 2020


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Stroke is a leading cause of morbidity and mortality in children. The etiologies, risk factors, and presentation of stroke differ from those of adults, and the diagnosis of stroke is often delayed in children. The management of pediatric stroke can be challenging because there are few data to support the efficacy of interventions.

Although pediatric stroke is rare, it is a leading cause of morbidity and mortality in children. The diagnosis of stroke is often delayed in children, which can contribute to death and disability. Management of pediatric stroke is challenging because there are few data to support the efficacy of interventions, and management is based on society guidelines and expert opinion, as well as extrapolation from adult stroke management.

This summary of the risk management pitfalls will help you avoid unwanted results while diagnosing and treating pediatric stroke in your ED.

1. “Stroke is an adult disease! This child was previously healthy; he can’t be having a stroke.”

Though stroke is uncommon in children, it does occur. Even previously healthy young children can experience stroke. A recent upper respiratory infection can increase the risk of stroke in an otherwise healthy child.

2. “I obtained a CT scan instead of an MRI because it’s too difficult to obtain an MRI in the ED, and it won’t give me management-changing information.”

Though CT scan may yield important diagnostic information, MRI is the preferred modality for pediatric stroke. MRI can better detail AIS and CSVT in addition to common stroke mimics. Delaying MRI delays definitive diagnosis, treatment, and possible prevention of future stroke.

3. “This child’s hemiparesis was likely Todd paralysis because he had a seizure prior to arrival.”

Children with stroke can present with seizure. New-onset focal seizures, prolonged paralysis, other neurological deficits, or stroke risk factors should prompt evaluation for stroke.

4. “The child presented with altered mental status, but there were no focal neurologic signs, so stroke was not on my differential diagnosis.”

In the case of ischemic stroke, children are more likely than adults to present with nonfocal signs and symptoms (eg, altered mental status), making the diagnosis especially challenging. A high level of suspicion for stroke must be maintained.

5. “This patient was last well 2 hours ago, and he has a PedNIHSS score of 10. The CT scan showed no hemorrhage, so I don’t need to involve neurology prior to giving tPA.”

While some specialists may recommend thrombolytics in pediatric AIS, emergency clinicians should never make this decision on their own. tPA may be reasonable in some situations under the guidance of a neurologist with experience treating pediatric stroke. Vascular imaging that demonstrates complete or partial occlusion of the vessel is required, in addition to other radiologic, laboratory, and clinical criteria. The safety and efficacy of thrombolytics in children have not been studied adequately.

6. “The patient was not moving his left arm as well as his right. He was complaining of a headache, so I thought he probably had a complex migraine.”

The presence of a headache does not rule out stroke in a child. Complex migraines in children are more commonly associated with visual and sensory changes rather than weakness, and migraine should be a diagnosis of exclusion.

7. “The patient had just came back from a CT scan when the lab called to report a critical glucose value of 20 g/dL.”

It is important to check the point-of-care glucose level in any child with stroke-like symptoms, because hypoglycemia can cause focal neurological changes and is an easily reversible stroke mimic. Checking the glucose level before sending the child for a CT scan may save them from unnecessary radiation.

8. “My patient with sickle cell disease had evidence of an ischemic stroke. Her hemoglobin was 8 g/dL, so I didn’t think she needed a blood transfusion.”

The treatment goal for AIS in patients with sickle cell disease is to increase the hemoglobin level to 10 to 11 g/dL via exchange transfusion. If the hemoglobin level is < 10 g/dL and exchange transfusion is not readily available, simple transfusion of red blood cells to a level of 10 g/dL is usually recommended.

9. “I highly suspected stroke in my patient. I thought an MRI brain scan should be sufficient imaging.”

Much of pediatric AIS is due to an arteriopathy. Obtaining vascular imaging with the initial imaging is helpful to immediately identify the cause of the patient’s AIS and to inform treatment and prevention of future stroke. This is especially important if the patient is going to be sedated for the MRI, so the patient does not have to be sedated more than once.

10. “I was concerned the patient had intracerebral hemorrhage, so I rushed him to the CT scanner before wasting time with IV placement or other resuscitation.”

While it is important to rapidly diagnose and contact neurosurgery in the case of a hemorrhagic stroke, it is also important to prevent secondary brain injury from causes such as hypoxia or hypotension/hypertension. Interventions such as IV placement and supplemental oxygen or intubation should be performed to stabilize the patient prior to obtaining imaging.

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Test Your Knowledge: Rash and Fever in the Pediatric Patient January 21, 2020


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Rash and fever are some of the most common chief complaints presenting in emergency medicine. The evaluation of skin rashes in the febrile pediatric patient includes a broad differential diagnosis and utilizing the signs and symptoms to identify red flags, such as hemodynamic instability, erythroderma, desquamation, petechiae/purpura, mucous membrane involvement, and severe pain, in the history and physical examination that require a high index of suspicion for worrisome disease.

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Review this Pediatric Emergency Medicine Practice issue to get up-to-date on common and life-threatening skin rashes with fever in children, guidance for differentiating the types of infections based on signs and symptoms, indications for diagnostic studies, and recommendations for treatment of pediatric skin rash with fever in the emergency department.

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Treatment Pathway for the Management of a Pediatric Patient With Hypothermia January 17, 2020


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Hypothermia occurs when the core body temperature falls below 35ºC (95ºF) due to primary exposure (eg, environmental exposure) or secondary to other pathologies. Infants, children, and adolescents are at higher risk for primary cold injuries due to a combination of physiologic and cognitive factors, but quick rewarming and appropriate disposition can result in survival and improved neurological outcomes. Treatment for cold injuries is guided by severity and can include passive or active measures.

This clinical pathway will help you improve care in the management of patients who preset with hypothermia. Download now

Treatment Pathway for the Management of a Pediatric Patient With HypothermiaTreatment Pathway for the Management of a Pediatric Patient With Hypothermia

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Test Your Knowledge: Managing Dislocations of the Hip, Knee, and Ankle in the ED January 9, 2020


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Dislocation of the major joints of the lower extremities–hip, knee, and ankle–can occur due to motor-vehicle crashes, falls, and sports injuries. These are painful presentations in the trauma ED that must be managed quickly to avoid morbidity, disability, and even possible amputation.

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Need a refresher on the subject? Review the summary below:

Points from Managing Dislocations of the Hip, Knee, and Ankle in the Emergency Department (Trauma CME):

  • 90% of hip dislocations are posterior; 10% percent are anterior.
  • Typically, an AP pelvic radiograph is adequate to diagnose a hip dislocation. Judet views are help­ful in diagnosing associated fractures.
  • Traumatic dislocations of the native hip should be reduced within 6 hours to reduce the risk of avascular necrosis and posttraumatic arthritis.
  • The Allis, Bigelow, Captain Morgan, Rocket Launcher, and East Baltimore Lift techniques can all be used to reduce a hip dislocation. None have proven to be superior to the others; the choice can be made according to provider capability and preference.
  • All hip reduction methods can be used on both native and prosthetic hips.
  • Consider an ultrasound-guided fascia iliaca com­partment block to augment and reduce proce­dural sedation and analgesia.
  • All hip fracture dislocations should be deferred to orthopedic surgery.
  • After reduction of a native hip dislocations, a CT scan should be obtained. The patient will need to be admitted to the hospital.
  • Many knee dislocations spontaneously reduce. Maintain a low threshold of suspicion for this injury, as missing a knee dislocation could have catastrophic consequences.
  • In any knee dislocation with a pulse deficit, perform immediate reduction without imaging. Delays longer than 8 hours have a higher inci­dence of amputation.
  • After reduction of the dislocated knee, patients should be admitted for serial vascular examina­tions or vascular imaging should be obtained. Compartment syndrome is a delayed complica­tion of knee dislocations.
  • Ankle dislocations require immediate recognition and prompt reduction, as they can be associated with significant neurovascular, skin, and soft-tissue complications.
  • Subtalar dislocations are rare, but appear similar to ankle dislocations. Attempting to reduce a subtalar dislocation before imaging may lead to worsening of the dislocation.
  • Emergent orthopedic consultation and post-reduction CT are necessary after reduction of a dislocated ankle.

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What’s Your Diagnosis? A 1-year-old Boy With Rhinorrhea January 3, 2020


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But before we begin, check out if you got last month’s case right, about a 4-year-old with fever, right leg pain, and difficulty walking. Click here to check out the answer!

Case Presentation: a 1-year-old boy with rhinorrhea, congestion, cough, and fever

You arrive to a busy afternoon shift in the ED. Your first patient is a 1-year-old boy with rhinorrhea, congestion, cough, and 3 days of fever up to 39.4°C (103°F), measured rectally. His parents state that he has been playful at home and continues to eat and drink normally. They have been giving him acetaminophen and ibuprofen sporadically, but today he developed a generalized rash, and they became concerned. His vital signs are as follows: temperature, 38.7°C (101.7°F); heart rate, 135 beats/min; and blood pressure, 85/55 mm Hg. On examination, the rash is macular, erythematous, and blanching, but his eyes and mouth appear normal.

Does he need laboratory workup, or can you safely offer supportive care? Should he be on isolation, either for his own safety or for the safety of others?

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What’s Your Diagnosis? 76-year-old With Chest Pain January 3, 2020


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 2 comments

But before we begin, check out if you got last month’s case, on the timing-and-triggers approach to the patient with acute dizziness, right. Click here to check out the answer!

Case Presentation: A 76-year-old woman presents to the ED with chest pain

A 76-year-old woman presents to the ED with chest pain.

She said that for the past month she has been getting short of breath more easily on her daily walks, with occasional discomfort in her chest, requiring her to stop and rest.

Two hours prior to ED arrival, she was doing yard work and developed chest pain that was much more severe. The pain is located in the center of her chest, and she describes it as a “pressure” sensation. Her only past medical history is hypertension.

In the ED, her vital signs are within normal limits and her exam is unremarkable. Her ECG shows nonspecific ST-segment flattening, and her initial troponin is 0.09 ng/mL (reference range, 0-0.04 ng/mL).

Your intern asks if she can go home since her troponin is low and she looks well…

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Test Your Knowledge: Pediatric Septic Arthritis and Osteomyelitis Management in the ED December 18, 2019


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Septic arthritis and osteomyelitis often present with a subacute course of illness and vague signs and symptoms. Both diagnoses are true emergencies, and these conditions must be promptly diagnosed and treated to avoid adverse sequalae.

Patients with SA or OM classically present with fever, ill appearance, malaise, pain, and swelling of the involved joint. Given the large differential diagnosis for a limping child, obtaining a thorough history and physical examination is paramount to narrowing the differential diagnosis and to obtain the appropriate testing and treatments.

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Review this Pediatric Emergency Medicine Practice issue to get up-to-date evidence-based recommendations for the diagnosis and management of pediatric patients with septic arthritis and/or osteomyelitis and offers guidance for appropriate antibiotic treatment.

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Pitfalls To Avoid With Septic Arthritis And Osteomyelitis In Pediatric Patients December 11, 2019


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Septic arthritis and osteomyelitis often present with a subacute course of illness and vague signs and symptoms. Both diagnoses are true emergencies, and these conditions must be promptly diagnosed and treated to avoid adverse sequalae.

Septic arthritis and osteomyelitis in pediatric patients represent true emergencies, and can quickly threaten life and limb. A high index of suspicion should be maintained, as these conditions often present with a subacute course of illness and vague signs and symptoms. Septic arthritis and osteomyelitis can occur concurrently, so suspicion for one should also prompt investigation for the other.

The diagnostic evaluation should include blood work as well as samples from the infected joint or bone for culture. Management with antibiotics is a standard approach, but the duration of antibiotic therapy is controversial.

These risk management pitfalls will help you avoid unwanted outcomes in pediatric patients with septic arthritis and osteomyelitis in your ED.

1. “The patient did not have a fever, so I attributed the pain to minor aches and pains.”
Not all patients with SA and OM will present with fever. Patients may present with a subacute presentation with some pain and refusal to bear weight. There may also be a history of preceding minor trauma.

2. “The patient presented with vague/nonspecific pain. I didn’t consider a bone or joint infection.”
Both pediatric SA and OM present in a similar fashion, and the initial symptoms may be vague and nonspecific, so it is important to maintain a high index of suspicion. A thorough musculoskeletal examination should be completed and imaging should be obtained in order to fully assess the joint/bone involved.

3. “The x-ray was normal, so I did not obtain further labs or imaging studies.”
X-rays are often normal in cases of both pediatric SA and OM, especially early in the disease course. Signs on plain radiography that are consistent with SA include distention of the joint capsule, increased opacity within the joint, displacement of muscle surrounding the joint by capsular distention, increased distance between the subchondral ends of bone, and, occasionally, subluxation of the joint. Findings on plain radiography that are consistent with OM are bone destruction and periostitis, which appears as soft-tissue swelling, periosteal elevation, and lytic sclerosis.

4. “The MRI was negative, so we did not pursue further investigation for SA and OM.”
MRI is not 100% diagnostic and can give a false-negative result. In such cases, CT imaging can be pursued.

5. “The ESR and WBC results were below the established Kocher criteria.”
The ESR may be normal early in the course of SA, and neonates may have low WBC counts due to leukopenia. CRP is a useful early marker of disease and can be trended to monitor the response to antibiotics. Even in the absence of an elevated ESR and WBC, a patient with fever and refusal to bear weight still has a 40% risk of having SA.

6. “The initial lab results were not consistent with SA, so I decided to forego obtaining the arthrocentesis.”
Synovial fluid analysis remains the gold standard for diagnosis of a septic joint. The joint fluid analysis can be completed via arthrotomy, arthrocentesis, or ultrasound-guided needle aspiration.

7. “I wanted to start the antibiotics promptly, so I did not obtain a blood culture.”
With an increase in antibiotic-resistant organisms, it is essential to obtain culture specimens from as many sites as possible, such as blood, joint fluid, and bone, so initial empiric antibiotics can be modified to treat the specific microbiologic pathogen.

8. “I wanted to tailor the antibiotics to the specific microbial pathogen, so I decided to wait for culture results prior to starting antibiotic therapy.”
Ideally, empiric antibiotic therapy should be started after obtaining a reliable culture sample, but the initiation of antibiotics should not be delayed while awaiting results of culture samples. The antibiotics are geared toward the organisms known to be the most likely cause of SA and OM.

9. “We were so busy in the ED that I decided to discharge some other patients first before obtaining the appropriate labs and imaging studies.”
Time is of the essence for both pediatric SA and OM. It is imperative that the appropriate workup be initiated as soon as either diagnosis is suspected so that antibiotics can be initiated in order to avoid danger to both life and limb.

10. “I instructed my patient to continue antibiotics at least until his symptoms improved.”
Incomplete antibiotic treatment duration and/or microbial coverage can attribute to antibiotic resistance and recurrence of symptoms. Both OM and SA require initial inpatient parenteral antibiotic therapy followed by oral antibiotic therapy lasting several weeks.

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Influenza Risk Management Pitfalls to Avoid in the Emergency Department December 11, 2019


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Patients presenting to the ED with “influenza-like illness” (cough, sore throat, fever) are typical in the fall and winter. How can you tell whether a patient might have influenza and infect others with a potentially dangerous strain?

Emergency clinicians must be aware of the current diagnostic and therapeutic recommendations for influenza and the available resources to guide management.

Because influenza infections can present with a wide range of nonspecific clinical signs and symptoms and numerous possible complications, emergency clinicians must be keenly alert to this possible diagnosis. A knowledge of the local seasonal prevalence of influenza as well as the specific strains circulating within a particular region are crucial for appropriate diagnostic and treatment decisions and will help to limit unnecessary testing when empiric therapy would be more appropriate.

These risk management pitfalls will help you avoid unwanted outcomes when treating a patient with a flu-like symptoms in the ED.

1. “The fever was low-grade; I thought the baby just had a cold.”
The presenting signs and symptoms of influenza infection are nonspecific, and a diagnosis based on clinical presentation alone becomes less accurate in children aged < 3 years. Although many children will experience a mild disease course and can be managed with supportive therapy, patients aged < 2 years are at high risk for a more severe clinical course. Be vigilant and have a high index of suspicion for possible influenza infection in high-risk populations, especially when disease prevalence is high.

2. “The patient had an infiltrate on chest x-ray, so bacterial pneumonia appeared to be the clear diagnosis.”
Numerous secondary complications can stem from a primary influenza infection. When addressing and treating these complications, do not overlook the possibility of a primary influenza infection and the need for medical management. In certain clinical situations, treatment with antiviral medications as well as antibacterial medications may be indicated.

3. “I thought I would just let it run its course.”
Many previously healthy people can be treated with supportive therapy alone; however, you must be aware of the numerous risk factors that are likely to result in a more severe disease course. For patients deemed well enough to be safely discharged from the ED, utilize shared decision-making with the patient and ensure a follow-up strategy is in place.

4. “It is the summer. Influenza occurs in the fall and winter, so I do not need to be concerned about it at this time of the year.”
Although influenza certainly exhibits seasonal fluctuations and regional outbreaks, the disease can occur year-round. Testing and possible empiric treatment of patients with an influenza-like illness are influenced by the regional prevalence of the disease, so monitor medical agencies that track the prevalence of influenza on a regional and national level, such as the CDC.

5. “My patient is pregnant and has influenza. The side-effect profile of antiviral medications concerns me, so I feel better treating her with supportive care.”
Pregnancy is a risk factor for a more severe disease course during an influenza infection. Initial CDC epidemiologic data from the last 10 influenza seasons indicate that some of the highest rates of morbidity and mortality are among pregnant women, which confirms the necessity of antivirals in this population.

6. “Medical knowledge has advanced over the past few decades, and now we have great antiviral medications. I do not need to worry about a devastating influenza infection today.”
While it is true that medical science has advanced considerably since the pandemic of 1918, influenza remains a significant threat. The ability of the virus to undergo genetic reassortment allows for the rapid development of new influenza strains to which the population has little or no immunity. Resistance to antiviral medications has been known to develop quickly for certain influenza strains and appears to be a rapidly increasing concern over time.

7. “Flu is everywhere. I don’t have the time to consult the CDC website. I will just give oseltamivir to my patient and be done with it.”
Even in times of epidemic influenza infection, numerous strains can be circulating at a given time within a particular region. In past epidemics, there have been reports of influenza strains resistant to oseltamivir. Thus, without knowing the prevalence of local strains, one might mistakenly choose an antiviral agent that will prove less effective on those strains. Treatment with more than 1 agent may even be indicated in some regions until more formal strain-specific diagnostic testing can be undertaken. Since certain medications are effective against only influenza type A, the local prevalence of any type B influenza should be determined in order to select the appropriate drug therapy.

8. “I see so many patients in the ED every hour. I can’t possibly wear a mask and wash my hands for every patient. Plus, I must have been exposed to influenza 100 times already.”
Maintaining effective infection control is crucial to protecting not only other patients in the ED but also healthcare staff. Patients suspected of having influenza require appropriate isolation, and strict hand-washing as well as personal protective equipment (eg, masks) are necessary to protect healthcare staff who are in direct contact with patients. The Strategic Plan for Management of an Influenza Outbreak, published by the American College of Emergency Physicians, is a good resource to ensure the highest level of preparedness on the part of the ED staff as well as their ability to handle a surge in patient volume that can be expected during a disease pandemic.

9. “The WHO has declared a pandemic. I feel better giving all my suspected influenza patients antiviral therapy, since I don’t want anyone to have a poor outcome.”
Declaration of a pandemic does not necessarily mean that the particular infectious organism is more virulent. It merely recognizes that the disease is spreading worldwide. Pandemics can occur during both mild and more severe disease outbreaks.

10. “I performed a rapid influenza test and it was negative, so I am safe sending my patient home on supportive therapy alone.”
Numerous forms of testing are available to detect influenza infection. Rapid diagnostic tests help guide clinicians in their immediate management decisions, but the quality of the specimen and the skill of the technician performing the assay can influence results. Certain rapid assays are specific for influenza type A, so knowing which strains are circulating locally is important. In times of high disease prevalence, the chance that a given patient with an influenza-like illness actually has the disease is increased, as are the number of false-negative results obtained from rapid diagnostic testing. At such times, empiric therapy based on clinical presentation alone is advised for patients at high risk. In more severely ill patients, viral culture and PCR testing are indicated when the initial rapid test yields a negative result.

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Christmas Is The Busiest Air Travel Season. Would You Be Ready In An Emergency Happened Mid-Flight? December 10, 2019


Posted by Andy Jagoda, MD in: Brain Tease , add a comment

A Common Occurrence

More than 4 billion passengers are expected to fly in 2019, and more than 60,000 medical emergencies are expected to occur during commercial flights.1 Emergency clinicians who work with acutely ill patients may have had the experience of boarding an aircraft and wondering what they would do if a medical emergency occurred.

“Should I respond?”

“What kinds of medications and equipment are aboard?”

“Would I be legally protected if something went wrong?”

These questions can be paralyzing and prevent otherwise highly trained medical personnel from delivering life-saving care.

Lifelong Learning, Applied

Megan Carman, NP, encountered one of those 60,000+ inflight medical emergencies just last month. She used the Emergency Medicine Practice issue, “Assisting With Air Travel Medical Emergencies: Responsibilities and Pitfalls” to familiarize herself with the roles, equipment, and protections available if called upon to respond to an in-flight medical emergency. Little did she know, Carman would be putting that knowledge to use shortly thereafter.

“How helpful that inflight emergency module was! Right after I read it, I was on a flight and a passenger started seizing. I knew to ask for the drugs and which ones they would have and to ask for IV supplies, and when people got upset about why we weren’t going to land, I told them it was a pilot decision and the average cost of landing. Also, when an anesthesiologist, who was also on the plane, was hesitant to help, I was able to tell him there are specific protections for medical providers who assist on planes as long as you are not grossly negligent or acting out of scope… Thank you for all this great info!” -Megan Carman, NP

Carman and many other Emergency Medicine Practice subscribers have specifically noted that they would be more likely to volunteer to assist with an inflight medical emergency after reading this issue.

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Test your knowledge


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The correct answer: B.

1. Peterson DC, Martin-Gill C, Guyette FX, et al. Outcomes of medical emergencies on commercial airline flights. N Engl J Med. 2013;368(22):2075-2083. (Retrospective review; 11,920 in-flight medical emergencies)