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


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

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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The correct answer: A.


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


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

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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What’s Your Diagnosis? A 4-year-old with fever, right leg pain, and difficulty walking November 29, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 3 comments

But before we begin, check out if you got last month’s case right, about a 7-year-old boy after a generalized seizure lasting 2 minutes Click here to check out the answer!

Case Presentation: a 4-year-old with fever, right leg pain, and difficulty walking

A 4-year-old boy presents to the ED with intermittent fever, right leg pain, and difficulty walking the last 3 days. His parents report that the child has a history of sickle cell disease and takes folic acid and penicillin for infection prophylaxis. The patient has never had surgery. On physical examination, there is point tenderness over the right thigh and an area of overlying edema, and the boy’s vital signs are within the normal limits for his age. You order a complete blood cell count, erythrocyte sedimentation rate, C-reactive protein, blood cultures, bone culture, and plain radiography.

What special bacterial pathogen must be considered in this case? How does this affect antibiotic treatment?

Case Conclusion

The 4-year-old boy with intermittent fever, right leg pain, and difficulty walking over the last 3 days was diagnosed with OM of the right femur. Since Salmonella is the most common cause of OM in patients with sickle cell disease, empiric treatment covering Salmonella was started. The bone culture grew out Salmonella. The patient was treated with vancomycin and ciprofloxacin parenterally for 5 days; he was then transitioned to oral therapy with a third-generation cephalosporin to complete 4 weeks of antibiotic therapy.

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


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

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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Brain Teaser: Do you know which of the following patients meets the criteria for anaphylaxis? June 24, 2019


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Test your knowledge and see how much you know about recognition and treatment of anaphylaxis in pediatric patients.

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The correct answer: A.

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Clinical Pathway for Diagnosis of Anaphylaxis in Pediatric Patients June 7, 2019


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

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. An allergic reaction is an overreaction of the immune system to a foreign substance (allergen). Anaphylaxis is a type of an allergic reaction that is an
acute, severe systemic hypersensitivity reaction that can rapidly lead to death.

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.

This clinical pathway will help you diagnose pediatric patient with anaphylaxis. Download now.

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A 3-year-old girl with a known peanut allergy May 31, 2019


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

Case Recap:
A 3-year-old girl with a known peanut allergy arrives to your ED via EMS. The girl was given a cookie by a classmate and immediately developed a generalized urticarial rash. EMS personnel gave her 12.5 mg of oral diphenhydramine and transported her to the ED. On examination, the patient has a heart rate of 160 beats/min with normal oxygenation and perfusion. She has bilateral periorbital swelling, without respiratory distress, wheezing, vomiting, or diarrhea. The accompanying daycare teacher tells you that the girl has previously been admitted to the intensive care unit for anaphylaxis.

You call the girl’s parents for more information and wonder what to do in the meantime. Is diphenhydramine sufficient treatment for this patient? Are corticosteroids indicated? Is this just an allergic reaction or could it be an anaphylactic reaction? What are the criteria for diagnosis of anaphylaxis? What are the indications for administering epinephrine in patients with anaphylaxis?

Case Conclusion:
The parents of the 3-year-old girl stated that the girl’s previous anaphylactic reaction began with urticaria and facial swelling that progressed, resulting in a critical care admission for airway compromise due to angioedema. You administered epinephrine 0.01 mg/kg IM for suspected anaphylaxis and observed the patient in the ED for 4 hours. The girl had complete resolution of the facial swelling and urticarial rash. You reviewed the signs and symptoms of anaphylaxis with the parents, discussed allergen avoidance, and demonstrated appropriate use of an epinephrine autoinjector. You discharged the patient with a prescription for 2 epinephrine autoinjectors and an anaphylaxis action plan.

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Brush up on most recent best practices in evaluating and treating pediatric patients with anaphylaxis in the ED with the latest issue of Pediatric Emergency Medicine Practice issue, Anaphylaxis in Pediatric Patients: Early Recognition and Treatment Are Critical for Best Outcomes.

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Fever, chills, and abdominal pain — Brain Teaser. Do you know the answer? October 24, 2018


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

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

The correct answer: C.

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Treatment Pathway for Initial Management of Patients with Sepsis October 17, 2018


Posted by Andy Jagoda, MD in: Feature Update , 3 comments
Sepsis is a common and life-threatening condition that requires early recognition and swift initial management. Diagnosis and treatment of sepsis and septic shock are fundamental for emergency clinicians, and include knowledge of clinical and laboratory indicators of subtle and overt organ dysfunction, infection source control, and protocols for prompt identification of the early signs of septic shock.
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This clinical pathway will help you improve care in the initial management of patients with sepsis. Download now.
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To Discharge Or Not — Sepsis In The ED Conclusion October 12, 2018


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 1 comment so far
Case Recap: 
A 45-year-old man with hypertension and prostate cancer in remission presents complaining of 3 days of burning with urination, fevers, and chills. His vital signs are: heart rate, 110 beats/min; respiratory rate, 20 breaths/ min; blood pressure, 130/90 mm Hg; SpO2, 98% on room air; and temperature, 38.4°C (101.2°F). He is alert and fully oriented. His physical exam reveals mild suprapubic tenderness without rebound or guarding and bilateral costovertebral angle tenderness. Lab findings include a WBC count of 18,000 with 5% bands, a creatinine of 1.5 mg/dL, a platelet count of 130 x 103/mm3, 80 WBCs on urinalysis with positive nitrite and leukocyte esterase, and a serum lactate of 1.2 mmol/L. After receiving ibuprofen and a fluid bolus, the patient feels better and states, “I need to go get my dog!” The nurse asks you if she can remove the IV for the patient to be discharged, which sounds reasonable, but something worries you…
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Case Conclusion:
The 45-year-old man with the urinary tract infection had a SOFA score of 2 and met the Sepsis-3 definition of sepsis, due to pyelonephritis. The patient was convinced to stay in the hospital, had 2 sets of blood cultures drawn, 30 mL/kg of IV fluids administered, and a dose of ceftriaxone 2 grams IV administered. His vital signs remained stable, and the patient was admitted to a monitored hospital bed. He was discharged 2 days later to continue oral antibiotics.
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Congratulations to Rachael Kinuthia, Micelle Jo Haydel, Annie Nunley PA-C, Dennis Allin, and Walter L Novey — this month’s winners of the Emergency Medicine Practice Audio Series Vol IV
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