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


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

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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What’s Your Diagnosis? a 7-year-old boy after a generalized seizure lasting 2 minutes November 1, 2019


Posted by Andy Jagoda, MD in: What's Your Diagnosis , 4 comments

But before we begin, check out if you got last month’s case right, about the 9-month-old infant gasping for air. Click here to check out the answer!

Case Presentation: a 7-year-old boy after a generalized seizure lasting 2 minutes

A 7-year-old boy is brought in by ambulance after a witnessed generalized seizure lasting 2 minutes at home. He has no history of prior seizures. Upon arrival to the ED, he appears postictal and is moving all of his extremities. His blood glucose is 110 mg/dL. His vital signs are: temperature, 36.9°C (98.5°F); heart rate, 60 beats/min; blood pressure, 110/70 mm Hg; respiratory rate, 14 breaths/min; and oxygen saturation, 98% on room air. The boy vomits while the nurse is trying to obtain IV access.

Per the mother, the boy has been receiving chemotherapy for lymphoma and was complaining of a headache earlier in the day. He has no history of intrathecal chemotherapy. The mother does not think he had any head trauma recently.

You know that the child needs brain imaging, but you are uncertain which imaging would be most useful…

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!

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What’s Your Diagnosis? Pain Management: Beyond Opioids November 1, 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, on nonconvulsive status epilepticus, right. Click here to check out the answer!

Case Presentation: A 73-year-old woman in the ED after “twisting” her ankle

A 73-year-old woman with a history of peptic ulcer disease and stage 3 chronic kidney disease presents to the ED after “twisting” her ankle. She tried acetaminophen at home, but it didn’t adequately alleviate her pain. Currently, she complains of 6/10 pain at rest. She has mild swelling and tenderness at the posterior edge of her lateral malleolus. You order an ankle x-ray to evaluate for fracture and consider giving her oxycodone…

You wonder whether there is a better and safer alternative…

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!

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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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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.

Case Conclusion

You quickly determined that your patient had severe bronchiolitis, and you knew that aggressive management was required. You placed the patient on pulse oximetry because the infant had wheezed previously, and started a trial of a nebulized bronchodilator with oxygen while closely monitoring his clinical response to treatment. Your patient’s respiratory rate was still in the 70s, with minimal decreases in the work of breathing. His pulse oximetry level was 87% on room air, so you administered supplemental oxygen via HFNC. The patient started to cry without tears, and you noticed his dry mucous membranes, so you administered IV fluids. His respiratory rate was 55 breaths/min with no retractions, and he was able to take his bottle for only a brief period even after the nurse suctioned his nasal secretions. His SpO2 level remained at 90% on room air. You decided to admit the patient because his tachypnea was leading to compromised oral intake and because of his persistent hypoxia, and you kept him on the HFNC in the meantime.

Review the issue to find out more about 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!

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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?

Case Conclusion

The 81-year-old woman with AMS was evaluated by a neurologist on the floor. Her EEG showed irregular, rhythmic, generalized 2.0–2.5 Hz sharp-and-slow wave complexes that ceased after 10 mg of IV diazepam. Later, her husband noted that her daily lorazepam had recently been discontinued abruptly due to a change in insurance. The patient was diagnosed with NCSE. NCSE can develop in a patient with or without underlying epilepsy, and should be included in the differential of unexplained AMS, especially in the setting of chronic benzodiazepine use. A high level of suspicion is essential for early diagnosis, but urgent confirmatory EEG is required.

Review the issue to find out more about 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!

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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

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Brain Teaser: When should ketorolac be avoided? August 22, 2019


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

Test your knowledge and see how much you know about pediatric pain management in the emergency department.

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 guidance on assessing pain in pediatric patients and provides evidence-based recommendations for developing strategies to successfully manage pain in pediatric patients.