How Will Your ED Fare This Halloween? Management of Anaphylaxis in Pediatric Patients October 20, 2019


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Anaphylaxis is a time-sensitive, clinical diagnosis that is often misdiagnosed because the presenting signs and symptoms are similar to those of other disease processes. Many cases of anaphylaxis are misdiagnosed or undertreated. The signs and symptoms of anaphylaxis are similar to other common illnesses, which can make diagnosis challenging. Atypical anaphylaxis can be even more difficult to diagnose, because some of the typical signs of anaphylaxis are not present.

Test your knowledge and see if you’d recognize a pediatric patient with anaphylaxis!


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The correct answer: A.

Review this Pediatric Emergency Medicine Practice issue to get up-to-date on management of anaphylaxis in pediatric patients in the ED.

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


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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


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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


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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?


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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.