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Right for Halloween: Clinical Algorithm for Pediatric Patients with Multiple Injuries October 10, 2019

Posted by Andy Jagoda, MD in : Feature Update , add a comment

When children with multiple serious injuries present to the ED, how do you ensure that you identify and address all of their injuries?

Management of the child with multiple traumatic injuries can be challenging, and important injuries may not be readily recognized. Early recognition of serious injuries, initiation of appropriate diagnostic studies, and rapid stabilization of injuries are key to decreasing morbidity and mortality in the multiply injured pediatric trauma patient. The differential diagnosis for these patients is wide, and treatment is targeted to the specific injuries.

This clinical flowchart provides a systematic approach to the management of pediatric patients with multiple traumatic injuries. Download now.

Clinical Pathway for the Management of a Pediatric Patient With Multiple Traumatic Injuries

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Concussion Aftercare Guidelines for the ED October 10, 2019

Posted by Andy Jagoda, MD in : Feature Update , add a comment

One important aspect of concussion management for the emergency clinician is the provision of adequate aftercare instructions at the time of discharge from the ED. This requires a paradigm shift for the emergency clinician, as discharging a head-injured patient was primarily focused on providing precautions for potential deterioration.

Patients with severe symptoms may be concerned about their ability to recover and the long-term implications, due to heightened media attention on concussion. An understanding of the expected course of recovery can be very helpful to the patient and family, providing reassurance that the majority of patients with concussion will recover fully.

Instructions for aftercare may include a period of rest, but should allow for limited, progressive cognitive and physical activity as tolerated by the patient and as symptoms improve. Emergency clinicians should not create disability by recommending strict rest. Several studies have found no benefit in the prescription of strict rest when compared to the resumption of moderate cognitive or physical activity. Brown et al demonstrated improved recovery in children who were provided with moderate cognitive rest compared to no cognitive rest, but there was no additional benefit with extremes of cognitive rest. It has also been shown that patients who resumed moderate levels of cognitive or physical activity recovered better than those with strict rest or resumption of high levels of activity.

While strict rest may inhibit recovery, the discussion with the patient must be balanced by maintaining a healthy respect for the vulnerability of the concussed brain. Rodent studies have clearly demonstrated that there is a window of vulnerability after a concussion, during which even a mild repeat injury significantly increases the risk of a complicated recovery. MRI spectroscopy studies in humans have demonstrated neurometabolic changes that persist beyond apparent clinical resolution of the concussion, but the clinical implications of these findings are not yet clear. Patients should be counseled on the risks of re-injury and should not return to sport or high-risk physical activities, such as bike riding, until cleared from the concussion during a follow-up medical visit.

When providing aftercare instructions, the emergency clinician should advise patients and caregivers that return to school is appropriate once severe symptoms have improved. Return to school typically can take place within 48 to 72 hours after the injury. Academic adjustments may be needed to support recovery in the school environment. The primary care clinician or concussion specialist is more suited than the emergency clinician to work with the patient’s school on specific plans for return to school. It is not necessary to keep students out of school until they are symptom free, as doing so increases the risk for development of social isolation, stress from missed school work, and/or school avoidance behaviors.

Sleep disturbance is almost universal in concussion and can be a significant source of disability and delayed recovery. The emergency clinician should counsel patients on sleep hygiene to help prevent a disturbed sleep cycle, as patients may spend more time than normal sleeping during the early course of recovery. Approximately 1 to 2 weeks after the injury, increased sleep often gives way to day-night reversal, difficulty falling asleep, and difficulty staying asleep.

Patients should be advised to eliminate napping within a few days after the injury and should be counseled that proper sleep hygiene techniques should be implemented within a week of the injury. The burden of electronic device use by patients should not be underestimated, as this can contribute to sleep disturbance even without concussion. Constant audible alerts and emission of blue light from electronic devices can contribute to sleep disturbance. Proper sleep hygiene techniques are outlined in Table 7.

Table 7. Proper Sleep Hygiene Techniques

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Test Your Knowledge: Nonconvulsive Status Epilepticus in the ED October 3, 2019

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

Nonconvulsive status epilepticus (NCSE) is characterized by persistent change in mental status from baseline lasting more than 5 minutes, generally with epileptiform activity seen on EEG monitoring and subtle or no motor abnormalities. NCSE can be a difficult diagnosis to make in the emergency department setting, but the key to diagnosis is a high index of suspicion coupled with rapid initiation of continuous EEG and early involvement of neurology.

When a patient presents to the ED with new-onset altered mental status or unusual behavior without visible convulsive activity, how can you tell if it is nonconvulsive status epilepticus?

Can you get it right?


Did you get it right? Click here to find out!

The correct answer: D.

Check out the issue on Nonconvulsive Status Epilepticus: Overlooked and Undertreated (Pharmacology CME) to brush up on the subject. Plus earn CME for this topic by purchasing this issue.

What’s Your Diagnosis? a 9-month-old infant gasping for air September 30, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 1 comment so far

But before we begin, check out if you got last month’s case right, about the 11-year-old boy with acute abdominal pain. Click here to check out the answer!

Case Presentation: an 9-month-old infant gasping for air

As your shift is winding down at 4 AM, a mother brings in her 9-month-old infant, whom she describes as “gasping for air.” The baby has had a runny nose and cough for a few days as well as a low-grade fever, but now he is breathing rapidly and wheezing, with lower intercostal retractions.

The mother states that the infant has had wheezing in the past, and she asks if he might have asthma since “it runs in the family.” She also indicates that in the last 12 hours, he has not taken his usual amount of fluids.

His oxygen saturation level is 87% on room air.

You begin to think… should I treat this as reactive airway disease, asthma, or bronchiolitis? When should I give the patient albuterol, nebulized epinephrine, or oxygen? Does the infant need steroids? You also wonder whether this patient is going to tire and require assisted ventilation or whether there are any other alternatives to intubation.

Leave your solution in the comments below and review the issue to find out what was the authors’ recommendation.

Not a subscriber? You can find out the conclusion and if you got it right, next month when a new case is posted, so stay tuned!

Click to review Pediatric Emergency Medicine Practice

What’s Your Diagnosis? Nonconvulsive Status Epilepticus: Overlooked and Undertreated September 30, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 1 comment so far

But before we begin, check out if you got last month’s case, on assistance with air travel emergencies, right. Click here to check out the answer!

Case Presentation: An 81-year-old woman presents with 1 day of behavioral changes

An 81-year-old woman presents with 1 day of behavioral changes. On examination, she is disoriented, with no focal neurologic findings and no evidence of seizure activity. Her medical history is remarkable for anxiety, arthritis, and hypertension; she has no history of stroke, trauma, or immunocompromise. Her medications include furosemide, lorazepam, and acetaminophen. After an extensive workup in the ED including ECG, CBC, CMP, UA, and
brain CT, all of which were normal, she was admitted to the floor.

You wonder: Is there something you forgot to consider in your differential diagnosis?

Leave your solution in the comments below and review the issue to find out what was the authors’ recommendation.

Not a subscriber? You can find out the conclusion and if you got it right, next month when a new case is posted, so stay tuned!

Click to review this Emergency Medicine Practice Issue

Brain Teaser: Signs of pneumothorax when seen on thoracic ultrasound September 13, 2019

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

The pediatric patient is arguably more suited for emergency ultrasound than the adult patient. Children generally have a smaller body habitus than adults and, therefore, less tissue for the ultrasound beams to penetrate. This often leads to clearer images of the different organ systems, which should yield better diagnostic accuracy.

Test your knowledge and see how much you know on pediatric ultrasound!


Did you get it right? Click here to find out!

The correct answer: D.

Review this Pediatric Emergency Medicine Practice issue to get up-to-date on POCUS in the ED.

Already a subscriber? Earn CME for this topic by logging to take your CME test.

Clinical Pathway for Management of Hemorrhage in Patients Taking Direct Oral Anticoagulant Agents September 10, 2019

Posted by Andy Jagoda, MD in : Feature Update , 1 comment so far

Direct oral anticoagulant (DOAC) agents have become commonly used over the last 9 years for treatment and prophylaxis for thromboembolic conditions, following approvals by the United States Food and Drug Administration.

These anticoagulant agents, which include a direct thrombin inhibitor and factor Xa inhibitors, offer potential advantages for patients over warfarin; however, bleeding emergencies with DOACs can present diagnostic and therapeutic challenges because, unlike traditional anticoagulants, their therapeutic effect cannot be easily monitored directly with common clotting assays.

This clinical pathway will help you improve care in the management of hemorrhage in patients taking direct oral anticoagulant agents. Download now.

Clinical Pathway for Management of Hemorrhage in Patients Taking Direct Oral Anticoagulant Agents

Get access to more pathways with an individual or group subscription. Visit www.ebmedicine.net/EMPinfo to find out more!

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Test Your Knowledge: Concussion in the ED September 10, 2019

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

An increasing number of patients with concussive injuries are presenting to the ED, due to a combination of factors, including media attention to sport-related concussion, early dedication to competitive sport, and improved screening and diagnostic tools for concussion.

Emergency clinicians play an important role in diagnosing concussion, initiating treatment, and providing concussion education to patients and their caregivers to optimize recovery.

Can you get it right?


Did you get it right? Click here to find out!

The correct answer: D.

Check out the issue on Concussion in the Emergency Department: A Review of Current Guidelines to brush up on the subject. Plus earn CME for this topic by purchasing this issue.

Clinical Flowchart for the Diagnosis of Appendicitis in Pediatric Patients September 10, 2019

Posted by Andy Jagoda, MD in : Feature Update , add a comment

Appendicitis is the most common condition in children requiring emergency abdominal surgery. Delayed or missed diagnosis in young children is common and is associated with increased rates of perforation. Although several scoring systems have been developed, there is still no consensus on clinical, laboratory, and imaging criteria for diagnosing appendicitis.

The dangers associated with misdiagnosis, delay, and perforation make quick and accurate diagnosis of appendicitis essential. This flowchart provides guidance for the management of children with appendicitis

Click the image to download your flowchart.

Clinical Pathway for the Diagnosis of Appendicitis in Pediatric Patients

Get access to more pathways with an individual or group subscription. Visit www.ebmedicine.net/PEMPinfo to find out more!

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What’s Your Diagnosis? 11-year-old boy with acute abdominal pain August 29, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , 5comments

But before we begin, check out if you got last month’s case right, about the 8-year-old boy presenting to the ED after falling at a local playground. Click here to check out the answer!

Case Presentation: an 11-year-old boy with acute abdominal pain

An 11-year-old previously healthy boy presents to the ED on a busy Saturday evening. He has acute abdominal pain that started 18 hours ago as diffuse periumbilical abdominal pain. Within the last 3 hours or so, the pain migrated to the right lower quadrant and worsened in severity. The child says the bumps on the car ride to the hospital were painful, and hopping up and down makes the pain worse. He says it seems to be a bit better when he lies still and does not move. Oral ibuprofen has not really helped the pain. The patient has not eaten a meal all day and has vomited 3 times today. On presentation, he has a temperature of 38.3°C (101°F). He is fully immunized and does not have any upper respiratory symptoms. He has never had similar pain in the past and has no history of previous
abdominal surgeries. He has a normal genitourinary examination. He has obvious discomfort with palpation of his abdomen with maximum tenderness in the right lower quadrant. He exhibits guarding and rebound tenderness.

His mother asks you whether this could be appendicitis, and whether he will need surgery. You begin to think…

Is this appendicitis? What else could it be? How will you definitively determine the diagnosis? What laboratory evaluation and imaging tests should you order? It is now 2:00 AM. If the patient definitely has appendicitis, does he need an emergent appendectomy or can it wait?

Case Conclusion

You sent a CBC and CRP for the 11-year-old boy with abdominal pain and vomiting. The WBC count and CRP were both elevated. An appendix ultrasound showed a dilated, noncompressible appendix with mesenteric fat stranding and appendiceal wall hyperemia, and you diagnosed the boy with appendicitis. The on-call pediatric surgeon was contacted and asked that you start antibiotics and admit the patient for appendectomy in the morning.

Review the issue to find out more recommendations.

Not a subscriber? You can find out the conclusion and if you got it right, next month when a new case is posted, so stay tuned!

Click to review Pediatric Emergency Medicine Practice

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Last Modified: 10-20-2019
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