Medication Errors

Medication Errors

Certainly, the PedEM Morsels promote a need for vigilance!  Vigilance is required to find those troublesome conditions that masquerade as benign conditions (see Inborn Errors of Metabolism, Meningococcemia, and Neonatal Seizures for a few examples).  Vigilance, however, is not just useful when considering a diagnosis: it is also necessary when discussing anticipatory guidance and the medical plan.  Medication Errors are a significant problem that a little preemptive action can help avoid.

 

Giving Medicine is Tricky

  • Medication errors are a common cause of adverse events and are more often seen in pediatric patients than adults.
    • Kids’ various sizes (both in weight and body surface area) and metabolic rates create challenges.
    • The fact many pediatric medications are liquid creates another challenge.
  • Even the experts are susceptible to error.
    • The chaotic environment of the ED, certainly enhances the chances of error (Leape, 1991).
    • Protective systems can help decrease medication errors in the hospital (Damhoff, 2014).
      • Some examples:
        • Electronic ordering systems
        • Avoiding often confused units of measure
        • Using weight-based dosing
        • Pediatric-specific pharmacy
        • Pharmacist in the ED
      • Still no system is fool-proof and requires vigilance.
  • If the experts are susceptible to error, how can we expect parents and care-givers to get it right?
    • An estimated 71,224 ED visits per year were made for unintentional overdose in children (Schillie, 2009).
      • ~34% were for over-the-counter (OTC) medications
      • ~14% were for medication errors / misuse
    • The odds are stacked against families!
      • Parents may not know the child’s specific and current weight at the time of medication administration.
      • Health Literacy and Numerical Literacy varies greatly amongst all patients and impacts interpretation of medication instructions (Bailey, 2009).
      • OTC medications may exist in various concentrations complicating administration.
      • It has been found that OTC medications often contain variable and inconsistent dosing directions (Yin, 2010).
      • OTC measuring devices have also been found to be inaccurate, inconsistent, and confusing.
      • There are a variety of measuring devices, often not standardized.
        • Measuring cups, syringes, droppers, “teaspoons,” etc.
        • Medicine cups have been shown to be related to a high occurrence of dosing errors (Tanner, 2014).

 

A Teaspoon Should NOT Be For Medicine

  • Parents who use teaspoon or tablespoon units had TWICE the odds of making an error! (Yin, Pediatrics 2014)
    • While a teaspoon is a unit of measure, it also often confused with the household utensil, which may vary greatly in actual size.
    • Abbreviations can be confusing: “tsp” can be misinterpreted as “tbsp” and vice versa.
  • Advocate for milliliters as the unit of measure.

 

Educate and Simulate

  • We all know that simulation strategies have benefited our processes of medical education… hands-on helps the memory.
  • Use this strategy for patients and parents as well.
  • The use of both education and demonstration have been found to be more effective at reducing liquid medication dosing errors (Yin, Academic Pediatrics 2014).
  • Establish systems in your ED that encourage this process to help avoid preventable medication errors.
    • Use a oral syringe with milliliter measurements.
    • Discuss the appropriate dose and frequency of the medication.
    • SHOW the family how to fill the syringe to the appropriate dose. Ensure that this is not ambiguous.
    • Have the family teach/show you how they will administer the medication at home.
    • Discharge with clear instructions illustrating the key points again.

 

References

Yin HS1, Dreyer BP2, Moreira HA2, van Schaick L2, Rodriguez L3, Boettger S2, Mendelsohn AL2. Liquid medication dosing errors in children: role of provider counseling strategies. Acad Pediatr. 2014 May-Jun;14(3):262-70. PMID: 24767779. [PubMed] [Read by QxMD]

Yin HS1, Dreyer BP2, Ugboaja DC2, Sanchez DC2, Paul IM3, Moreira HA2, Rodriguez L4, Mendelsohn AL2. Unit of measurement used and parent medication dosing errors. Pediatrics. 2014 Aug;134(2):e354-61. PMID: 25022742. [PubMed] [Read by QxMD]

Koumpagioti D1, Varounis C2, Kletsiou E2, Nteli C3, Matziou V4. Evaluation of the medication process in pediatric patients: a meta-analysis. J Pediatr (Rio J). 2014 Jul-Aug;90(4):344-55. PMID: 24726455. [PubMed] [Read by QxMD]

Damhoff HN1, Kuhn RJ2, Baker-Justice SN1. Medication preparation in pediatric emergencies: comparison of a web-based, standard-dose, bar code-enabled system and a traditional approach. J Pediatr Pharmacol Ther. 2014 Jul;19(3):174-81. PMID: 25309147. [PubMed] [Read by QxMD]

Neuspiel DR1, Taylor MM2. Reducing the risk of harm from medication errors in children. Health Serv Insights. 2013 Jun 30;6:47-59. PMID: 25114560. [PubMed] [Read by QxMD]

Tanner S1, Wells M, Scarbecz M, McCann BW Sr. Parents’ understanding of and accuracy in using measuring devices to administer liquid oral pain medication. J Am Dent Assoc. 2014 Feb;145(2):141-9. PMID: 24487605. [PubMed] [Read by QxMD]

Yin HS1, Wolf MS, Dreyer BP, Sanders LM, Parker RM. Evaluation of consistency in dosing directions and measuring devices for pediatric nonprescription liquid medications. JAMA. 2010 Dec 15;304(23):2595-602. PMID: 21119074. [PubMed] [Read by QxMD]

Schillie SF1, Shehab N, Thomas KE, Budnitz DS. Medication overdoses leading to emergency department visits among children. Am J Prev Med. 2009 Sep;37(3):181-7. PMID: 19666156. [PubMed] [Read by QxMD]

Bailey SC1, Pandit AU, Yin S, Federman A, Davis TC, Parker RM, Wolf MS. Predictors of misunderstanding pediatric liquid medication instructions. Fam Med. 2009 Nov-Dec;41(10):715-21. PMID: 19882395. [PubMed] [Read by QxMD]

Madlon-Kay DJ1, Mosch FS. Liquid medication dosing errors. J Fam Pract. 2000 Aug;49(8):741-4. PMID: 10947142. [PubMed] [Read by QxMD]

Leape LL1, Brennan TA, Laird N, Lawthers AG, Localio AR, Barnes BA, Hebert L, Newhouse JP, Weiler PC, Hiatt H. The nature of adverse events in hospitalized patients. Results of the Harvard Medical Practice Study II. N Engl J Med. 1991 Feb 7;324(6):377-84. PMID: 1824793. [PubMed] [Read by QxMD]

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Developmental Milestones in the ED

Developmental Milestones

 

Full Disclosure: I am the proud product of Combined Emergency Medicine and Pediatric training (thank you mentors Mattu, Rogers, Winters, Carraccio et al at U of Maryland).  As such, I worked nearly equal amounts of time in the Emergency Department (caring for kids and adults) as I did in my Pediatric clinic over 5 years of residency.  That being said, there is a reason I do Emergency Medicine… I could not stand going through the assessment of kids’ Developmental Milestones in the clinic!  Certainly it is important… but not for me in the ED… right?  Actually, there are many aspects of Developmental Milestones that can be useful to the vigilant clinician in the Pediatric ED.

 

Not Trying to Make You a PCP

  • Many of us in the ED have violent expulsion of gastric contents at the mere mention of considering any topic that is related to primary care.
  • While that is understandable (much like, we would not expect or want a Primary Care Physician to be expert in the EM realm), it is still useful to know some topics that bridge both worlds.
    • Some EM clinicians are serving as the only access to care a patient has… and need to know some primary care issues.
        • Almost 30% of 6- to 36-month-old children presenting to an urban PED without prior developmental concerns screened positive for possible delay. (Grossman, 2010)
    • Prescription of Controller Medications for Asthma is a good example of this (see Twitter conversation for additional thoughts).
  • Childhood Development is another topic that is not typically placed within the EM realm.
    • A full development assessment is actually beyond what can be done in a typical pediatrician’s office schedule.
    • Knowledge of basic developmental milestones, however, can help detect important aberrations that warrant further assessment.
    • This is particularly true with respect to the very young, as this can have implications in their neurologic exam.
    • This is similar to how knowledge of typical growth estimates can help you manage a child in the ED.

 

Developmental Milestones Basics

 

Typical Infant Developmental Milestones

  • Again, kids achieve milestones are various paces… so these are just estimates… but can help define marked abnormalities.
  • Motor
    • Head Posture / Control
      • 8 weeks – can hold head up while prone
      • 12 weeks – has some head lag when being pulled from supine position
      • 20 weeks – no head lag
      • 6  months – complete head control
    • Fine Motor
      • 2 months – grasps offered item
      • 4 months – reaches for objects. Brings hands to mouth (now we are in trouble)
      • 6 months – transfers objects form one hand to another
    • Gross Motor
      • 2 months – begins to push up while prone
      • 4 months – able to roll from tummy to back (essentially pushes self over). Bears weight on legs when feet are on a surface. Sits with curved spine.
      • 6 months – able to roll from back to tummy. Can sit without support.
      • 9 months – sits with straight spine.
      • 18 months – should sit, stand, and walk independently.
  • Social / Language
    • 2 months – attempts to look at parents.  Smiles.  Coos.
    • 4 months – smiles at people spontaneously.
    • 6 months – indicates desire to be picked up.  Knows familiar faces and recognizes when someone is a stranger.  Babbles.
    • 9 months – the height of separation anxiety! Plays “peek-a-boo” and waves “bye-bye.”  Understands “No.”
    • 12 months – knows one – two words.
    • 18 months – knows three – six words (body parts often).
    • 24 months – uses two word phrases.
    • 36 months – uses three word sentences.
  • Cognitive
    • Language and Social milestones are closely tied with Cognitive milestones, particularly early on.
    • 2 months – regards faces, has differential coos and cries and can indicate wants.
    • 4 months – reaches for objects, uses hands and eyes together.
    • 6 months – shows curiosity. Uses visual and oral exploration of environment.
    • 9 months – has object permanence (looks for item when it is hidden). Learns interactive games.
    • 12 months – can follow simple instructions. Bangs objects together.

 

References

Noritz GH, Murphy NA; Neuromotor Screening Expert Panel. Motor delays: early identification and evaluation. Pediatrics. 2013 Jun;131(6):e2016-27. PMID: 23713113. [PubMed] [Read by QxMD]

Grossman DS1, Mendelsohn AL, Tunik MG, Dreyer BP, Berkule SB, Foltin GL. Screening for developmental delay in high-risk users of an urban pediatric emergency department. Pediatr Emerg Care. 2010 Nov;26(11):793-7. PMID: 20944512. [PubMed] [Read by QxMD]

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Mechanical Ventilation for Severe Asthma

Mechanical Ventilation

“Wheezing” is a prominent complaint in the Ped ED and it has been a frequent topic of the PedEM Morsels.  We have covered a wide variety of Asthma management aspects: from initial therapies (MDIs vs Nebs) to potential hydration issues; from the utility of Magnesium to the Heliox. We have also discussed more advanced topics like Noninvasive Ventilation and how to Avoid Oxygen Desats as well as Delayed Sequence Intubation.  While the goal is often to prevent intubation, occasionally, the only option is to use Mechanical Ventilation for your patient with Severe Asthma.  The question, then, is how to make the best of a bad situation.

Important Pathophysiology

  • There are several significant alterations that occur with acute, severe asthma exacerbations (Oddo, 2006).
    • Heterogenous and reversible increased airway resistance 
    • Severe limitation of expiratory flow
    • Premature airway closure
    • Lung hyperinflation
      • Decreased elastic recoil and increased FRC of up to 2 times normal and decreased
    • Chest wall dynamic changes
    • High intrinsic PEEP
  • These produce clinically apparent:
    • Respiratory fatigue
      • Increased utilization of accessory muscles of respiration
    • Ventilation/Perfusion Mismatch
      • Very heterogenous areas of lung parenchyma with varying degrees of aeration
    • Barotrauma
      • High pulmonary pressures
    • Hemodynamic instability
      • Increased intrathoracic pressures negatively influencing the cardiac venous return/Preload and, hence, cardiac output.

 

The Bad Situation: Needing to Intubate

  • Fortunately, most often the patient with severe Status Asthmaticus can be managed without intubating.
    • Recent population study found incidence of intubation for status asthmaticus was 0.55% (Sankeerth, 2014)
    • Unfortunately, mechanical ventilation is associated with higher mortality.
  • Indications for using Mechanical Ventilation for the patient with severe status asthmatics:
    • This is a Clinical Decision!
      • There is no lab value will define a need to intubate.
      • Progressive exhaustion/fatigue with Altered Mental Status are the primary reasons.
      • A cooperative patient, even if hypercapnic, may be managed with maximizing other therapies (see Noninvasive Ventilation and Magnesium).
      • Hypoxia is usually not the sole reason to intubate, as supplemental oxygen typically corrects this; however, severe VQ mismatch can occur and be problematic.  May require advanced techniques (see Delayed Sequence Intubation).
    • There is a portion of patient who will present with Acute Asphyxial Asthma (Maffei 2004).
      • These patients deteriorate rapidly and often require intubation upon arrival in the ED or within the first 30 minutes of management.
      • Interestingly, these children have shorter durations of mechanical ventilation.
    • Where you work plays a role (Shibata, 2014).
      • Transport from a community ED to a tertiary center may be more problematic if the child is already tenuous.

 

The Problem with Mechanical Ventilation

  • Intubating a child should never be considered cavalierly, but after successfully placing the ETT, the real tricky part begins: not causing more harm with the mechanical ventilation process.
  • Already the patient has severe hyperinflation, poor respiratory mechanics, and potential restricted preload.
  • Complications of mechanical ventilation
    • Hemodynamic instability following intubation.
      • Hypotension occurs as a result of worsening hyperinflation leading to decreased cardiac preload.
      • Cardiac Arrest can occur due to this progression as well.
    • Barotrauma
    • Pneumothorax
    • Ventilator Associated Pneumonia
      • Most common – accounting for ~10% of the complications (Sankeerth, 2014)

 

Making the Best of a Bad Situation

  • If you have been placed between the rock and the hard place, and now must use mechanical ventilation, consider the following:
    • Use a Cuffed Endotracheal Tube!
    • Initial Ventilator Settings (Oddo, 2006):
      • Mode: there is no evidence to support one mode over another. Many start with Volume-Control.
      • Tidal Volume: 6-10 ml/kg ideal body weight
        • Enough to move the chest.
      • Expiratory Time: 4-5 seconds
        • Inspiratory:Expiratory ratio may be 1:4, but can be as high as 1:8
        • Goal is to allow exhalation and avoid stacking breaths with barotrauma.
      • Resp Rate: Below physiologic rate for age.
        • Controlled Hypoventilation has been shown to be safe (Dworkin, 1989)
      • PEEP: zero (in acute phase. PEEP used once improving and weaning starts).
      • FiO2: can start at 100%, but titrate to keep sats >90%.
    • Keep the child adequately sedated!
      • Avoid patient-ventilator asynchrony.
      • Also helps decrease CO2 production.
      • Ketamine is a useful med to consider!
      • It is best to avoid prolonged neuromuscular paralysis if you are able to.
    • Keep Plateau Pressures <30 cmH20
      • Increased risk of barotrauma above this level.
      • Measured by an end-inspiratory pause of several seconds in a system without leaks (hence, the cuffed ETT).

 

The Bad Situation Just Got Worse

  • If, after initiation of mechanical ventilation, the patient become hemodynamically compromised:
  • Step 1 – Disconnect from the Ventilator and allow the chest to recoil.
    • If the hemodynamics improve, restart the mechanical ventilation at a lower tidal volume and respiratory rate.
    • If the hemodynamics don’t improve… move to step 2.
  • Step 2 – After you cry on the inside, consider typical complications.
    • Dislodged ETT tube
      • Using continuous End-Tidal CO2 Monitoring helps here!!
      • Videoscopic Laryngoscope and or Ultrasound can help reconfirm as well.
    • Obstructed ETT tube
      • Suction the tube
    • Pneumothorax
      • Bedside Ultrasound is going to be faster and more sensitive than the portable CXR.
    • Equipment Failure
      • Because some days are just that kind of day.

 

References

Wade A1, Chang C. Evaluation and Treatment of Critical Asthma Syndrome in Children. Clin Rev Allergy Immunol. 2014 Feb 1. PMID: 24488329. [PubMed] [Read by QxMD]

Rampa S1, Allareddy V, Asad R, Nalliah RP, Allareddy V, Rotta AT. Outcomes of invasive mechanical ventilation in children and adolescents hospitalized due to status asthmaticus in United States: a population based study. J Asthma. 2014 Oct 14:1-8. PMID: 25295383. [PubMed] [Read by QxMD]

Shibata S1, Khemani RG, Markovitz B. Patient origin is associated with duration of endotracheal intubation and PICU length of stay for children with status asthmaticus. J Intensive Care Med. 2014 May-Jun;29(3):154-9. PMID: 23753230. [PubMed] [Read by QxMD]

Nievas IF1, Anand KJ. Severe acute asthma exacerbation in children: a stepwise approach for escalating therapy in a pediatric intensive care unit. J Pediatr Pharmacol Ther. 2013 Apr;18(2):88-104. PMID: 23798903. [PubMed] [Read by QxMD]

Rubin BK1, Pohanka V. Beyond the guidelines: fatal and near-fatal asthma. Paediatr Respir Rev. 2012 Jun;13(2):106-11. PMID: 22475257. [PubMed] [Read by QxMD]

Oddo M1, Feihl F, Schaller MD, Perret C. Management of mechanical ventilation in acute severe asthma: practical aspects. Intensive Care Med. 2006 Apr;32(4):501-10. PMID: 16552615. [PubMed] [Read by QxMD]

Maffei FA1, van der Jagt EW, Powers KS, Standage SW, Connolly HV, Harmon WG, Sullivan JS, Rubenstein JS. Duration of mechanical ventilation in life-threatening pediatric asthma: description of an acute asphyxial subgroup. Pediatrics. 2004 Sep;114(3):762-7. PMID: 15342851. [PubMed] [Read by QxMD]

Dworkin G1, Kattan M. Mechanical ventilation for status asthmaticus in children. J Pediatr. 1989 Apr;114(4 Pt 1):545-9. PMID: 2494314. [PubMed] [Read by QxMD]

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Damage Control Resuscitation

Massive Transfusion

 

Damage Control Resuscitation has been the hot topic to discuss in the adult trauma bays.  Naturally, this conversation has been also heard more commonly during pediatric trauma resuscitations.  What is it and does it really apply to kids?  Great questions!  Fortunately, a nice review article was published last month (Hughes, Ped EM Care: 2014) that I encourage you all to read… but I’ll do my best to recap.

 

Damage Control Resuscitation

  • Strategies applied to caring for hemorrhagic shock in the severely traumatized patient.
    • Fortunately, the vast majority of your pediatric trauma patients will NOT fit into this category.
    • Intended for patients in whom severe hemorrhage necessitates transfusions of large-volumes of blood products.
  • Aimed at helping to avoid or diminish the Lethal Triad of Trauma Management: Acidosis, Hypothermia, Coagulopathy.
    • The traditional approach of giving large volumes of isotonic saline can exacerbate all of these conditions.
    • Even large volumes of PRBCs can lead to electrolyte changes (ex, hyperKalemia) and coagulopathy.
  • Has three core concepts:
    • Acute Coagulopathy of Trauma
    • Permissive Hypotension
    • Massive Transfusion & Hemostatic Resuscitation

 

Acute Coagulopathy of Trauma

  • The vast majority of healthy children do not require Coagulation studies prior to surgery (ex, the patient with appendicitis), unlike the adult population.
  • Interestingly though, it has been found that pediatric trauma patients can present with acute coagulopathy associated with their trauma.
    • This is distinct from the coagulopathy that can develop during the resuscitation due to administered therapies.
    • Theories = tissue factor release, Protein C activation, Hyperfibrinolysis.
    • Also studies that show association with Traumatic Brain Injury and acute coagulopathy.
  • This does not mean that ever kid in a car crash needs 1,000 labs looking for coagulopathy, though!

 

Permissive Hypotension

  • We all know that any hypotension that occurs during medical resuscitations is associated with higher mortality, but can hypotension be “ok” in trauma?
  • Observations that patients with uncontrolled hemorrhage may have worsening shock after IV fluids seem counterintuitive.
    • Perhaps the increased volume and/or pressure leads to a tenuous clot being dislodged.
    • Perhaps the increased volume further dilutes the already over-utilized coagulation factors.
    • Perhaps there is some other inflammatory change or cellular structure alteration (ex, swelling) as a result of the IV fluids.
  • The practice of Permissive Hypotension is the plan of tolerating below normal BPs and limiting IV fluids until definitive management of the bleeding can be performed (surgery or embolization).
    • What is the goal BP?  Dunno.
    • Ideally, you need to still maintain enough end-organ perfusion pressure to keep the vital organs alive.
  • It works in animals and some adults. How about kids?
    • While we are all mammals, pediatric patients may not benefit as much from this management strategy as adults or other studied animals.
    • Children are able to tolerate hypovolemia much better than adults.
      • Kids can compensate for up to 45% of blood volume loss prior to becoming hypotensive.
      • If you already have a child that is hypotensive, you are in the very deep dark woods.
    • Children are often have head injuries, which don’t respond well to hypotension.
    • There have been no pediatric studies that demonstrate utility in permissive hypotension in pediatric trauma patients to date.

 

Massive Transfusion Protocols & Hemostatic Resuscitation

  • Refers to the use of Fresh Frozen Plasma and Platelets along with Packed Red Blood Cells in ratios to approximate whole blood.
  • The best ratio is not known, but often protocols use 1:1:1.
  • Does it work in children?
    • Cases reports of non-traumatic, intra-operative hemorrhage being successfully managed with massive transfusion protocols.
    • No studies of pediatric trauma patients show any mortality benefit from massive transfusion protocols to date.

 

First do no harm!

  • Massive Transfusions have been associated with cardiac arrest in pediatric patients.
  • Transfusion-Associated Hyperkalemic Cardiac Arrest (TAHCA) is rare, but can occur.
  • Possible strategies to reduce the risk of TAHCA:
    • Use fresher RBCs for massive transfusions
    • Use Large Bore PERIPHERAL IVs instead of central lines (remember there is more resistance in a long central line)
    • Check for and correct electrolyte abnormalities frequently.

References

Hughes NT1, Burd RS, Teach SJ. Damage control resuscitation: permissive hypotension and massive transfusion protocols. Pediatr Emerg Care. 2014 Sep;30(9):651-6; quiz 657-8. PMID: 25186511. [PubMed] [Read by QxMD]

Lee AC1, Reduque LL, Luban NL, Ness PM, Anton B, Heitmiller ES. Transfusion-associated hyperkalemic cardiac arrest in pediatric patients receiving massive transfusion. Transfusion. 2014 Jan;54(1):244-54. PMID: 23581425. [PubMed] [Read by QxMD]

Parker RI. Transfusion in critically ill children: indications, risks, and challenges. Crit Care Med. 2014 Mar;42(3):675-90. PMID: 24534955. [PubMed] [Read by QxMD]

Nosanov L1, Inaba K, Okoye O, Resnick S, Upperman J, Shulman I, Rhee P, Demetriades D. The impact of blood product ratios in massively transfused pediatric trauma patients. Am J Surg. 2013 Nov;206(5):655-60. PMID: 24011571. [PubMed] [Read by QxMD]

Chidester SJ1, Williams N, Wang W, Groner JI. A pediatric massive transfusion protocol. J Trauma Acute Care Surg. 2012 Nov;73(5):1273-7. PMID: 23064608. [PubMed] [Read by QxMD]

Chidester SJ1, Williams N, Wang W, Groner JI. A pediatric massive transfusion protocol. J Trauma Acute Care Surg. 2012 Nov;73(5):1273-7. PMID: 23064608. [PubMed] [Read by QxMD]

Dehmer JJ1, Adamson WT. Massive transfusion and blood product use in the pediatric trauma patient. Semin Pediatr Surg. 2010 Nov;19(4):286-91. PMID: 20889085. [PubMed] [Read by QxMD]

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Anaphylaxis

Epi Early and Often

 

Sitting next to my son, who is rather red-cheeked with his current fever, consuming a herculean amount of cartoons, I was reminded of one of my favorite shows when I was young: GI JOE.  “Knowing is half the battle,” was imprinted within my being at an early age.  The Morsels have addressed many topics that hopefully augmented everyone’s “knowing.”  One topic that deserves some attention is Anaphylaxis.

{Yes, we just went from my febrile son, to GI JOE, to Anaphylaxis.  That is the transitive property of Morsel writing.}

Anaphylaxis: More Common than you Think

  • The incidence has increased with the implementation of the broader definition.
  • The incidence ranges from 100,000 to 500,000 per year in the USA.
  • Two-thirds of the annual cases are new cases.
  • Almost 1% of cases are fatal.
  • The incidence in food-related allergies has been increasing, so it is expected that anaphylaxis will also increase.
  • Estimated that a food-induced anaphylaxis presents to the ED every 6 minutes in the USA.

 

Anaphylaxis: The Criteria

  • The National Institute of Allergy and Infectious Diseases define anaphylaxis as a “serious allergic reaction that is rapid in onset and may cause death” and typically involves two or more organ systems.
  • Anaphylaxis is highly likely when ANY of the following criteria are met:
    • Acute Onset with involvement of skin, mucosal surfaces, or both AND
      1. Respiratory Compromise and/or
      2. Reduced BP or symptoms of end-organ dysfunction
    • Two or more of the following that occur rapidly after exposure to a likely allergen:
      1. Skin/Mucosal tissue involvement
      2. Respiratory Compromise
      3. Reduced BP or symptoms of end-organ dysfunction
      4. Persistent GastroIntestinal symptoms (ex, crampy pain, vomiting)
    • Rapid reduction in BP after exposure to known allergen.

 

Anaphylaxis: Important Points

  • The severity of an anaphylactic reaction cannot be predicted based on past reactions or risk factors.
  • Young children are tricky!
    • As with most conditions, the very young can be more difficult to diagnose.
    • The preverbal may not be able to express their symptoms clearly.
  • GastroIntestinal Symptoms are important to consider!
    • They are often under appreciated.
    • They have been found in over 50% of cases.
  • BiPhasic Reactions:
    • Occur in about 6% – 11% of children.
    • Usually manifest within the first 8 hours after exposure, but may be delayed up to 72 hours.
  • Treatment:
    • Epinephrine is the preferred 1st line therapy.
    • Antihistamines (H1 and H2 blockers) are useful for urticaria, nasal, and ocular symptoms, but not other symptoms.
    • Steroids have too slow of an onset to matter in the acute phase.

 

Anaphylaxis: “Epi Early and Often!”

  • Epi Early!
    • Epinephrine is the 1st line therapy for acute anaphylaxis.
    • Delayed administration of epinephrine has been associated with increased morbidity and mortality.
      • Unfortunately, several studies indicate that Epinephrine is either given in a delayed fashion or not at all during the acute phase.
      • This is true for patients/parents, EMS providers, as well as physicians.
    • Dose:
      • 0.01 mg/kg of the 1:1,000 solution; Max of 0.3 mg in children (0.5 mg in adults).
      • Autoinjectors: 0.15 mg dose for pts < 25kg; 0.3 mg for pts < 25 kg.
      • Exact dose is preferred for small infants and children.
    • Route Matters!
      • Intramuscular (IM) administration into the mid-anterolateral thigh is preferred.
      • IM provides faster rise in plasma and tissue concentrations than does the subcutaneous route.
  • Epi Often!
    • Epinephrine has a short half-life.
    • May need to repeat dose after 5 minutes.
    • Up to 20% of patients require more than one dose!
    • It is important to ensure patients have at least 2 doses of self-administered Epinephrine available to them in different environments (So prescribe 2 for home, 2 for school, etc).
  • There are no absolute contraindications to Epinephrine in this clinical setting.
    • Often concerns over adverse effects of epinephrine can delay it being given.
    • Appropriate doses of epinephrine rarely cause severe adverse reactions.

 

Moral of the Morsel: Epi Early and Often

  • Keep the broader criteria of Anaphylaxis on your radar screen.
  • Ask specifically about GI symptoms.
  • If the patient meets criteria, give Epi without Delay and consider additional dose in 5 minutes if not improving.
  • Get access and give IVF.
  • Other meds like antihistamines should not be given instead of Epinephrine.  They can be used as adjuncts, but do not let them distract the team from getting the Epinephrine in!
  • Patients then will require either prolonged observation (no standard, but often recommended to be 4-6 hrs) or hospitalization.

 

References

Chipps BE. Update in pediatric anaphylaxis: a systematic review. Clin Pediatr (Phila). 2013 May;52(5):451-61. PMID: 23393309. [PubMed] [Read by QxMD]

Tiyyagura GK1, Arnold L, Cone DC, Langhan M. Pediatric anaphylaxis management in the prehospital setting. Prehosp Emerg Care. 2014 Jan-Mar;18(1):46-51. PMID: 24028748. [PubMed] [Read by QxMD]

Benkelfat R1, Gouin S, Larose G, Bailey B. Medication errors in the management of anaphylaxis in a pediatric emergency department. J Emerg Med. 2013 Sep;45(3):419-25. PMID: 23478178. [PubMed] [Read by QxMD]

Grossman SL1, Baumann BM, Garcia Peña BM, Linares MY, Greenberg B, Hernandez-Trujillo VP. Anaphylaxis knowledge and practice preferences of pediatric emergency medicine physicians: a national survey. J Pediatr. 2013 Sep;163(3):841-6. PMID: 23566384. [PubMed] [Read by QxMD]

Lieberman P1, Nicklas RA, Oppenheimer J, Kemp SF, Lang DM, Bernstein DI, Bernstein JA, Burks AW, Feldweg AM, Fink JN, Greenberger PA, Golden DB, James JM, Kemp SF, Ledford DK, Lieberman P, Sheffer AL, Bernstein DI, Blessing-Moore J, Cox L, Khan DA, Lang D, Nicklas RA, Oppenheimer J, Portnoy JM, Randolph C, Schuller DE, Spector SL, Tilles S, Wallace D. The diagnosis and management of anaphylaxis practice parameter: 2010 update. J Allergy Clin Immunol. 2010 Sep;126(3):477-80. PMID: 20692689. [PubMed] [Read by QxMD]

Sampson HA1, Muñoz-Furlong A, Campbell RL, Adkinson NF Jr, Bock SA, Branum A, Brown SG, Camargo CA Jr, Cydulka R, Galli SJ, Gidudu J, Gruchalla RS, Harlor AD Jr, Hepner DL, Lewis LM, Lieberman PL, Metcalfe DD, O’Connor R, Muraro A, Rudman A, Schmitt C, Scherrer D, Simons FE, Thomas S, Wood JP, Decker WW. Second symposium on the definition and management of anaphylaxis: summary report–second National Institute of Allergy and Infectious Disease/Food Allergy and Anaphylaxis Network symposium. Ann Emerg Med. 2006 Apr;47(4):373-80. PMID: 16546624. [PubMed] [Read by QxMD]

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Appendicitis Clinical Decision Rules

Appendicitis

 

Often the Ped EM Morsels discuss diagnoses that emphasize astute clinical skills and vigilance while minimizing the importance of laboratory testing.  Appendicitis is a great example of this!

Many of you already know my disdain for the ubiquitous WBC count (otherwise known as the “Last Bastion of the Intellectually Destitute” – Amal Mattu) and are also aware of the many Myths that are associated with Appendicitis.  This month’s Annals of Emergency Medicine (2014, Oct; 64(4)) addresses another often encountered issue with Appendicitis: the Clinical Decision Rules.

 

Clinical Decision Rules

  • The practice of medicine is becoming more complicated everyday.
  • Ideally, we would like to ensure that all patients get superior care regardless of where they receive their care.
  • Clinical Decision Rules are aimed at helping providers deliver consistent and high quality care.
  • Clinical Decision Rules integrate various features (history, exam, simple labs, etc) in an effort to predict the likelihood of a specific disease/condition.
  • Useful Clinical Decision Rules would stratify patients into Low, Moderate, and High Risk Groups.
    • Low Risk – Condition ruled-out. No testing.
    • Moderate Risk – “Test Threshold” – Requires further testing.
    • High Risk – “Treatment Threshold” – Condition ruled-in. No Testing… just treat!

 

Appendicitis and Clinical Decision Rules

  • There are two widely used Clinical Decision Rules for Appendicitis.
    • Alvarado Score
    • Pediatric Appendicitis Score
  • The Alvarado Score has been found to have better test characteristics than the Pediatric Appendicitis Score (although they vary only slightly).
  • The Alvarado Score is a 10-point Score:
    • 1 point for -
      • Migration of Pain
      • Anorexia
      • Nausea or vomiting
      • Rebound Pain
      • Elevated Temperature (greater than or equal to 99.2 F)
      • Left Shift (greater than or equal to 75% PMNs)
    • 2 points for – 
      • Right Lower Quadrant Tenderness
      • Leukocytosis (greater than or equal to 10,000/microL).
  • The Pediatric Appendicitis Score gives only 1 point for leukocytosis and gives no points for rebound pain while adding 2 points for RLQ pain with coughing, jumping, percussion.
  • Unfortunately, often theses clinical findings are not reliably reproduced (we all know if the ask a patient a question 3 times you’ll get at least 2 different replies – “Did you vomit?” “No.” “Did you vomit?” “No.” “Did you vomit?” “Oh, you mean throw up? Yes I did.”).

 

Pretest Probability Matters

  • The Ebell and Shinholser paper nicely demonstrates the fact that the performance of the Clinical Decision Rule for appendicitis is dependent upon the pretest probability.
    • At a pretest probability of 33%, even an Alvarado Score of 9 or 10 does not cross the Treatment Threshold.
    • At a pretest probability of 66%, even an Alvarado Score of <4 does not define a useful Low Risk group.
  • What determines the clinician’s Pretest Probability??
    • While clinical experience and illness scripts certainly play a role in the estimation of the Pretest Probability,…
    • I would also suggest that the Clinical Variables scored in the Clinical Decision score play a significant role in the determination of a Pretest Probability.
    • So if a patient has migratory pain, nausea/vomiting, fevers, RLQ tenderness and rebound, both the Pretest Probability and the Alvarado Score will be high.
    • Experienced clinicians will often perform as well as Clinical Decision Rules.
  • Stratification is not precise.
    • Determining a Pretest Probability is dependent upon many variables.
    • Deciphering it all into a nice number like “33%” or “50%” or “66%” is difficult.
    • Often we default to a general gestalt.
    • This underscores that fact that our job is as much art as it is science.

 

Moral of the Morsel

  • The diagnosis of appendicitis is a difficult one.
  • The WBC count still is the Last Bastion of the Intellectually Destitute!
  • Clinical Decision Rules can help when incorporated into a Clinical Pathway that help to standardize care across a regional population.
  • Nothing is better than your clinical experience and acumen.

 

References

Ebell MH1, Shinholser J2. What Are the Most Clinically Useful Cutoffs for the Alvarado and Pediatric Appendicitis Scores? A Systematic Review. Ann Emerg Med. 2014 Oct;64(4):365-372. PMID: 24731432. [PubMed] [Read by QxMD]

Kharbanda AB. Appendicitis: do clinical scores matter? Ann Emerg Med. 2014 Oct;64(4):373-5. PMID: 24882663. [PubMed] [Read by QxMD]

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