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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Summary of Recommendations for ED Management of the Acute Bronchiolitis in Pediatric Patients November 7, 2019


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Differentiating bronchiolitis from asthma and reactive airway disease in young children can be challenging, and a rapidly changing clinical presentation can confound accurate assessment of the severity of the illness.

Acute bronchiolitis is the most common lower respiratory tract infection in young children that leads to emergency department visits and hospitalizations. Bronchiolitis is a clinical diagnosis, and diagnostic laboratory and radiographic tests play a limited role in most cases. While studies have demonstrated a lack of efficacy for bronchodilators and corticosteroids, more recent studies suggest a potential role for combination therapies and high-flow nasal cannula therapy. Frequent evaluation of patient clinical status including respiratory rate, work of breathing, oxygen saturation, and the ability to take oral fluids are important in determining safe disposition.

This summary of the treatment recommendations for pediatric bronchiolitis, supported by various guidelines provides, a systematic approach to ED assessment of such patients.

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Summary of Recommendations for ED Management of the Acute Bronchiolitis in Pediatric Patients

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Right for the Season: Clinical Flowchart for Management of Burns in the Emergency Department November 7, 2019


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Holidays are busy times for everyone, including emergency departments. Maybe it’s the rushing around during preparation or too many people in the kitchen, but inevitably someone gets hurt and burns are among the top injuries seen in the ED during the Thanksgiving holidays.

Thermal burn injuries are a significant cause of morbidity and mortality worldwide. In addition to treatment of the burns, emergency clinicians must assess for inhalation injury, exposure to toxic gases, and related traumatic injuries.

Priorities for emergency resuscitation include stabilization of airway and breathing, intravenous fluid administration, pain control, and local wound care. Special populations, including children and pregnant women, require additional treatment considerations. Referral to specialized burn care for select patients is necessary to improve long-term outcomes.

This pathway outlines evidence-based treatment strategies for treating thermal burn injuries in the ED.

Clinical Pathway for Management of Burns in the Emergency Department

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


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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

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


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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

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Clinical Pathway for the Diagnosis of Appendicitis in Pediatric Patients

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Ultrasound Assessment for Skull Fractures August 15, 2019


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The use of ultrasound at the point of care by emergency clinicians, as well as by other specialists, has become increasingly common over the last 25 years. Emergency POCUS can be used as a diagnostic test and also to visualize anatomy for procedural guidance. It allows the emergency clinician to rapidly rule in or rule out disease processes and guide ongoing investigation and management of patients in the ED.

Pediatric emergency ultrasound has been slower to progress than adult emergency ultrasound. However, the use of emergency ultrasound for pediatric patients has recently begun to formalize.

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.

Ultrasound can be used in the evaluation of children with blunt head trauma to assess for skull fractures. (See Figure Below) The presence of a skull fracture increases the risk of traumatic intracranial hemorrhage 4- to 6-fold.

While the absence of a skull fracture does not rule out the presence of intracranial injury, assessment for skull fracture has been used to risk stratify.

Skull Fracture on Ultrasound

Patients with blunt head trauma. In a meta-analysis published in 2000, skull x-rays had a sensitivity of 38% and a specificity of 95% when interpreted by radiologists. Given this poor sensitivity, skull x-rays have been falling out of favor for assessment of skull fracture. However, there has been a renewed interest in skull ultrasound as perhaps a better tool to assess for skull fracture and to risk stratify patients with blunt head trauma.

Technique
Skull ultrasound is performed with a high-frequency linear array probe. The probe should be placed on the area of the skull with maximal tenderness, hematoma, or other sign of possible fracture. It should be scanned in 2 planes, looking for disruptions in the cortex. Sutures can be differentiated from fractures by following the cortical break to a fontanelle and by scanning the contralateral side for comparison. Additionally, the cortical break in a fracture will appear ragged, with sharp margins, while a suture will have a smooth appearance.

Several prospective studies have evaluated bedside ultrasound for skull fractures in children. Rabiner et al pooled data from previous trials along with their own data. They reported a sensitivity of 94% and specificity of 96% for ultrasound detection of skull fractures. Parri et al performed another study not captured in the Rabiner et al study, and showed a sensitivity of 100% and a specificity of 95%, with 1 false-positive result. A limitation of these studies was that the ultrasounds were performed on patients for whom a CT scan was planned. Therefore, the study population was already determined to be at higher risk for injury as compared to the entire spectrum of head trauma patients presenting to the ED. Nonetheless, it can be concluded that the diagnostic accuracy of skull ultrasound is superior to that of skull x-ray.

Future Applications
The current trend in the evaluation and risk stratification of pediatric head trauma is the incorporation of clinical decision rules, with the PECARN pediatric head injury prediction rule being the most sensitive and most commonly used in the United States.56 An area of future research is the incorporation of skull ultrasound in conjunction with a clinical decision rule to better risk stratify patients and possibly further decrease the number of CT scans being performed.

To read more about the PECARN Pediatric Head Injury Prediction Rule, go to: www.ebmedicine.net/PECARN-head-rule

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Clinical Pathway for Emergency Department Management of Patients With Bariatric Surgery Complications August 14, 2019


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As bariatric procedures have become more common, more of these patients present to the emergency department postoperatively.

The most common complaints in these patients are abdominal pain, nausea, and vomiting, though each of the surgical procedures will present with specific complications, and management will vary according to the surgical procedure performed. Computed tomography is often the primary imaging modality, though it has it limits, and plain film imaging is appropriate in some cases.

This clinical pathway will help you improve care in the management of patients with bariatric surgery complications. Download now.

Clinical Pathway for Emergency Department Management of Patients With Bariatric Surgery Complications

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