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An 8-year-old boy presents to the ED after falling at a local playground July 30, 2019

Posted by Anna in : Uncategorized , 2comments

An 8-year-old boy presents to the ED after falling at a local playground. His mother, who was with him at the time of the injury, states that he was climbing out of a tree when he slipped and fell. He landed on his outstretched hands and is now complaining of right wrist pain. On examination, he has no open wounds, and he has a normal neurovascular examination, but he has an obvious deformity of his right forearm. The child describes his pain as 7/10.

You ponder how best to treat the child’s severe pain as quickly as possible….

What are your next steps?

Case Conclusion

To quickly address the 8-year-old boy’s arm pain, you ordered a dose of intranasal fentanyl at 1.5 mcg/kg. You instructed the nurse to draw up the IV formulation of fentanyl in a syringe and then attached an atomizer to the syringe. The nurse then administered half the dose into each of the patient’s nostrils. When you re-evaluated him 5 minutes later, his pain was significantly improved to 3/10. Eventually, the team was able to place an IV, and the boy’s fracture was successfully reduced while he was sedated with ketamine. The boy was discharged home, and dosing instructions for ibuprofen as needed for pain were given to his parents. You also provided a prescription for oxycodone for breakthrough pain, with specific instructions on its administration, storage, and disposal.

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How best to assess his anticoagulation status July 29, 2019

Posted by Andy Jagoda, MD in : What's Your Diagnosis , add a comment

As you begin your shift, the first patient is a 70-year-old man brought in for a ground-level fall with isolated head injury. A review of the patient’s history reveals atrial fibrillation, and he is currently on anticoagulation with apixaban. A rapidly obtained CT scan of the head shows
a subdural hematoma.

As you resuscitate the patient, you wonder how best to assess his anticoagulation status and how best to address reversal.

What are your next steps?

Case Conclusion

Your patient on apixaban with traumatic subdural hematoma received initial resuscitation focusing on maintenance of the airway, breathing, and circulation, as appropriate for head trauma. After reviewing your hospital’s policy on DOAC reversal and local availability of specific reversal agents for this DOAC, you administered a dose of 4-factor PCC at 50 units/kg in the ED. He was admitted to the neurosurgical ICU for continued care, and a repeat CT of the head showed no interval expansion of the hemorrhage.

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Most Common Risk Stratification Criteria for Management of Febrile Young Infants July 18, 2019

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

Due to an immature immune system and pathogens often specific to the age group, the young infant (generally aged < 60-90 days, depending on the specific study or review) is at high risk for serious bacterial infections (SBIs); in particular, urinary tract infection (UTI), bacteremia, and bacterial meningitis. Consequently, the febrile young infant with a rectal temperature ≥ 38°C (100.4°F) is commonly encountered in the emergency department (ED). The incidence of SBI in febrile infants aged < 90 days is 8% to 12.5%, and it is nearly 20% in neonates (aged ≤ 28 days). The incidence of potentially life-threatening bacteremia and/or bacterial meningitis (ie, invasive bacterial infection [IBI]) is approximately 2%.

Due to their lack of social responsiveness (eg, social smile) and verbal cues, even well-appearing febrile young infants may harbor an SBI, in contrast to well-appearing febrile older infants and children who are at lower risk for IBI. Multiple studies have demonstrated that both observation scales and clinician suspicion for SBI are poorly predictive of bacterial infection in febrile infants. Additionally, bacterial meningitis is the most common diagnosis involved in pediatric medical malpractice claims in the emergency department (ED).

Over 2 decades ago, several risk stratification criteria were created to identify febrile young infants at low risk for SBI, and the criteria have been utilized to potentially avoid hospitalization of certain low-risk patients. More recently, newer risk stratification algorithms that incorporate biomarkers such as procalcitonin (PCT) and C-reactive protein (CRP) have been developed and validated in febrile infants.

Among well-appearing febrile infants, neonates have the highest prevalence of SBI and IBI and the least reliable clinical examination. These infants should undergo a full sepsis evaluation, including CSF testing. While the Rochester criteria and the recently published PECARN prediction rule do not include routine CSF testing in this age group (see table below), infants classified as low-risk by any criteria may still have bacterial meningitis, so CSF testing is generally recommended for all infants aged ≤ 28 days. Consideration should be given to testing for HSV in the neonate aged ≤ 21 days, even in the absence of vesicles or maternal history of HSV infection.

This table will help you predict the risk stratification criteria for management of febrile young infants. Download now.

Table 4. Most Common Risk Stratification Criteria for Management of Febrile Young Infants

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Intravenous Thrombolysis in Acute Ischemic Stroke July 17, 2019

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

Stroke is the fifth leading cause of death in the United States and an important cause of long-term disability. Approximately 795,000 people suffer from stroke each year (610,000 primary strokes and 185,000 recurrent strokes),1 with ischemic stroke representing the vast majority of all stroke types (87%).

The cornerstone of acute ischemic stroke treatment relies on rapid clearance of an offending thrombus in the cerebrovascular system. Advanced neuroimaging and clinical trials, together with continuous adjustments of inclusion/exclusion criteria, have helped emergency clinicians to rapidly and more accurately identify the patients who will benefit from acute stroke treatment.

Inclusion and Exclusion of Intravenous Thrombolysis: A Changing Landscape

The American Heart Association (AHA) recently published updated guidelines for stroke management. Table 1, summarizes the updated 2018 AHA indications and contraindications for treatment with IVT. Every patient presenting with symptoms of acute stroke within 4.5 hours of last known well or usual state should be triaged for potential IVT. Patients should be evaluated with computed tomography (CT) scan of the brain and systolic blood pressure (SBP) should be maintained at < 185 mm Hg and diastolic blood pressure (DBP) at < 110 mm Hg. Every eligible patient should receive IVT without delay. Changes and adjustments of inclusion/exclusion criteria (in order to minimize the risk of any complication) have been made and are discussed in following sections.

Table 1. Eligibility Criteria and Exclusion Criteria for Intravenous Thrombolysis
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Brain Teaser: What is the appropriate management of this infant? July 17, 2019

Posted by Andy Jagoda, MD in : Brain Tease , 1 comment so far

Test your knowledge and see how much you know about management and treatment of young infants presenting with fever.

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

The correct answer: C.


Review this Pediatric Emergency Medicine Practice issue to get up-to-date on novel diagnostic tools such as procalcitonin, C-reactive protein, and RNA biosignatures as well as new risk stratification tools such as the Step-by-Step approach and the Pediatric Emergency Care Applied Research Network prediction rule to determine which febrile young infants require a full sepsis workup and to guide the management of these patients in the emergency department.

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Test Your Knowledge on Assessing Abdominal Pain July 17, 2019

Posted by Andy Jagoda, MD in : Brain Tease , 1 comment so far

Patients with abdominal pain are common in the ED, but you need a strategy for quickly identifying patients who are at high risk for life-threatening causes of pain.

The management of abdominal pain has changed significantly in the past 20 years, with increasing emphasis on identifying patients who are at high risk for occult pathology and worse outcomes. Test your knowledge of the most common causes of sudden-onset abdominal pain.

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

The correct answer: A.

Check out the issue on Assessing Abdominal Pain in Adults: A Rational, Cost-Effective, and Evidence-Based Strategy to brush up on the subject. Plus earn CME for this topic by purchasing this issue.

Febrile Young Infants In the ED — How do you Manage them? July 11, 2019

Posted by Robin Wilkinson in : Uncategorized , 4comments

Case Recap:
A 40-day-old girl presents to the ED in January for evaluation of a rectal temperature of 38˚C (100.4˚F). The history and physical examination are similar to an infant you saw in August, except that she has nasal discharge and a cough. Which risk stratification algorithm should you use for this infant? Would your workup change if a respiratory swab was positive for respiratory syncytial virus?

Case Conclusion:
Although the 40-day-old infant’s signs and symptoms were suggestive of a benign URI, you remembered that several studies demonstrated that infants in this age group (29-56 days) with documented RSV or influenza are still at risk for SBI, especially UTI, though the risk of IBI is lower in this age group compared with infants who have negative RSV or influenza testing. You ordered urine studies, blood culture, CBC, CRP, and PCT, given the non-negligible prevalence of IBI. The urinalysis was normal, the CBC showed a WBC of 10,000/mcL, the CRP was < 20 mg/L, the PCT was < 0.5 ng/mL, and the ANC was < 10,000 cells/mcL. Since the girl’s labs were reassuring and she was well appearing and feeding appropriately with reliable followup, you discharged her home without CSF testing and with close primary care follow-up the next day.

Did you get it right?

How Do You Manage Bariatric Surgery Complications? July 11, 2019

Posted by Robin Wilkinson in : What's Your Diagnosis , 2comments

Case Recap:
You are called to the bedside of patient who presents for nausea and vomiting. He is a 38-year-old man who is 2 weeks out from the placement of a laparoscopic adjustable gastric band. He reports that he had an acute onset of nausea and vomiting this evening. He is actively vomiting on presentation and complains of diffuse abdominal pain, but is hemodynamically stable. While attempting to contact his surgeon, you wonder what the best imaging modality is to make the diagnosis. What would you do?

Case Conclusion:
You returned to your patient, in whom you had a concern for a slipped gastric band. You considered obtaining either an upper GI series or CT scan with oral and IV contrast; after speaking to his surgeon, you decided on an upper GI series, as the patient was now more stable. The patient was admitted to the surgery service; on follow-up, you learned that the balloon was subsequently deflated/repositioned, and the patient was discharged home in stable condition.

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Last Modified: 10-16-2019
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