The top ten articles in Pediatric Emergency Medicine (2014 edition)

Check out my live-tweet of the top ten Pediatric Emergency Medicine articles of the year presentation at the American Academy of Pediatrics National Conference & Exhibition in San Diego, CA on Saturday, October 11, 2014. I’ll be exploring these topics in a more in depth fashion soon and discussing how they wight impact your practice and teaching.

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Check out the newest edition of the PEM Currents podcast on topical anesthetics

PEM Currents returns with an examination of the different topical anesthetics used in Emergency Department. Specifically, by listening to this edition you’ll learn about LET, EMLA and LMX and how you can add them to your repertoire for pre-procedure anesthesia in the ED.

You can download it on iTunes

Or listen right here via the embedded media player

 

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Why we do what we do: Intravenous magnesium for asthma exacerbations

So you’ve thrown the kitchen sink at a child with a moderate to severe asthma exacerbation. And despite the large hematoma on their forehead from the concussive effect of the faucet ricocheting off their skull they’ve not improved. What’s a clinician to do? Give intravenous magnesium sulfate, that’s what you should do. Interestingly we learned that it was valuable when treating pregnant women with preeclampsia that also happened to have asthma (if that’s apocryphal let me know). If you want, you can also review stratification of asthma severity before moving on.

Let’s run down some of the evidence in chronological order (I won’t include every study – just some illustrative examples):

Skobeloff et al. JAMA, 1989

An early RCT, done in adults, that randomized 38 patients moderate to severe asthma exacerbations to get IV mag vs placebo. The authors noted that the Mag group had better improvement in peak flow and fewer Mag patients were admitted (7 for Mag vs 15 for placebo).

Green et al. Annals of Emerg Med, 1992

The authors randomized 120 consecutive patients in a block manner (alternating Mag vs placebo days) and failed to show a reduction in admission rate –  22% in Magnesium group (95%CI 13-32), 17% in control (95%CI 10-26), p = 0.523. I included this study because the physicians weren’t blinded to the randomization. Does this impact how you assess the validity of the study?

Bloch et al. Chest 1995

Another adults only trial, this time involving 135 patients. They also noted a decreased risk of admission, 35.3% in the placebo group and 25.4% in the Mag group (p = 0.21). When they broke it down to moderate (FEV1 <75% predicted) and severe (FEV1 <25% predicted) they noted that only the severe group had significantly reduced admission rates. Specifically they stated that in the severe patients “admission rates were 78.6% (11/14) for the placebo-treated group and 33.3% (7/21) for the magnesium-treated group (p = 0.009). For the moderate patients, admission rates were 22.4% (11/49) for the placebo-treated group and 22.2% (10/25) for the magnesium-treated group (p = 0.98).” This study built upon Skobeloff by including more patients and stratifying severity.

Ciarrallo et al. J. Pediatr, 1996

A study on kids? Now you’re talking. This RCT of kids 6 to 18 years with peak flow rates <60% predicted following 3 nebulized treatments included 31 kids (15 Mag vs 16 placebo). The dose was 25mg/kg IV over 20 minutes – more on the dose in a little bit. The Mag group had higher serum Mag levels (only mean 1.3), and a better improvement in % increase in expected peak flow. They also noted that 27% of IV mag were discharged home vs 0% placebo; p = 0.03.

Ciarrallo et al. Arch Pediatr Adolescent Medicine

Ciarrallo followed up earlier work by going with a higher dose of IV Mag (40mg/kg) – more is better! This RCT involved 30 children age 6 to 18 that needed 3 back to back nebs (albuterol alone or combo of albuterol/ipratropium). They excluded febrile patients, as well as those with cardiac, renal or non-asthma pulmonary disease and theophylline use in the last week. Patients got IV Mag or placebo. The authors noted a reduced risk of admission 50% IV mag (8/16) vs 100% placebo (14/14); p=0.02, and improved respiratory scores at approximately one and a half hours (mean asthma score 1.4 for IV mag and 2.5 placebo; p<0.001). The small numbers limited the generalizability, but it was a start.


Let’s get meta

So, out of the 5 aforementioned studies, 4 showed a reduced risk of admission and improved pulmonary function or clinical asthma scores. Two are more germane to Pediatric Emergency Medicine as they included children. To better draw conclusions we’d need a meta analysis… And here you go, it’s from Rowe et al. in 2000. Overall the authors examined 7 studies with 665 patients and concluded the following:

  • The pooled results showed non-significant improvements in peak expiratory flow rates (weighted mean difference: 29.4 L/min; 95% confidence interval: -3.4 to 62)
  • In severe exacerbations alone peak expiratory flow rate improved by 52.3 L/min (95% CI: 27 to 77.5)and FEV1 improved by 9.8 % predicted (95% confidence interval: 3.8 to 15.8)
  • Admission to the hospital was not reduced overall – OR = 0.31 (95% CI: 0.09 to 1.02)
  • In severe patients those receiving Mag did see a reduced risk of admission (OR = 0.10, 95% CI: 0.04 to 0.27)
  • There were no worrisome or clinically relevant changes in vitals or adverse side effects

So what does this mean for me in the Emergency Department?

Well, if inhaled beta-agonists and iprotropium (remember, dounebs decrease the risk of admission) plus systemic glucocorticoids don’t help a child with a moderate to severe asthma exacerbation you should consider giving IV Magnesium. The best recommended dose is:

Magnesium sulfate 50 mg/kg IV over 20 minutes (max dose 2 grams)

Though the meta analyses failed to show problematic decreases in BP it is probably a good idea to give a 20 mL/kg NS bolus as well. Not only will this offset potential Mag induced peripheral vasodilation and resultant decrease in BP, but it will also augment cardiac preload, which can be negatively impacted by pulmonary hyperinflation and its effects on reducing venous return to the heart through the lungs.

Can I send a kid home after giving magnesium IV?

In short, yes you can – but this may not be the usual practice in your institution for a variety of reasons. You’ll want to make sure that the child is symptom free, not hypoxic, not expected to require albuterol more frequently than every four hours and have reliable transportation and primary care doctor follow up.


 

Want to learn more? Check out the following companion post:

Why we do what we do: Systemic corticosteroids in acute asthma exacerbations

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Take a break and bone up on injuries with Fracture Fridays

Did you know that there is a regular feature on PEMBlog called Fracture Fridays? Did you know that these posts are about fractures, and that they are released on Fridays? OK, so that last question was a bit pandering, of course you did. Well then, why don’t you check out a few of my favorite posts from the past couple of years and learn something about kids and their broken bones.

Boxers

HumerusJones

Triplane

 

 

 

 

ApophysisTibiaFingerFOOSH

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Briefs: Do we need antibiotics after I&D of a cutaneous abscess?

First of all, the proper and effective treatment of a cutaneous abscess is ALWAYS incision and drainage. With that out of the way, let us address the more controversial question. Should a child be prescribed antibiotics after I&D? We’ll look at the evidence as it stands then address the main question in a scenario-based approach. Certainly MRSA is the main reason why this question is so important to address. In some locales nearly all cutaneous abscesses will be caused by the aforementioned gram positive bacterium – see Fridkin and Moran et al NEJM for more. Most of the following studies discuss treatment failure as an outcome. In gereral this means that one or more of the following occurred within a set time period after I&D:

Return of any of the following symptoms at the original site of the I&D:

  • Erythema
  • Warmth
  • Induration
  • Fluctuance
  • Tenderness

Worsening symptoms requiring:

  • Further surgical drainage
  • Change in medication
  • Hospital admission for intravenous antibiotics

 

Let’s take a look at the evidence shall we?

Rajendran et al Antimicrob Agents Chemother, 2006

A RCT of 166 adults randomized to 7 days of placebo versus cephalexin. The primary outcome was treatment failure at 7 days. 70% of the abscess cultures had staph isolates, and of these isolates 87% were methicillin resistant. Placebo cure rate was 90.5% (95% CI, 0.82 to 0.96) and 84.1% (95% CI, 0.74 to 0.91) in the cephalexin group P=0.0006 (95% confidence interval, -0.0461 to 0.0472; P = 0.25). Sure, they randomized to an antibiotic that MRSA laughs at, but both groups had high cure rates.

Paydar et al Arch Surgery 2006

This retrospective review of 376 patients with abscesses noted a high rate of MRSA isolates, but a low rate of provision of effective antibiotics (Only 25 of 284 MRSA cases). Only one patient failed treatment in this inappropriate group (osteomyelitis). This study used data from 2000 to 2001 and certainly is limited by its design.

Ruhe et al Clin Infect Dis 2007

A retrospective review of 492 adult patients with 531 abscesses, all MRSA positive. Most had an I&D performed. Treatment failure occurred in 8%. Therapy was successful for 95% (296/312) of patients who received an active antibiotic vs 87% (190/219) who didn’t (p=.001). On logistic regression analysis the authors noted that use of an inactive antimicrobial agent was an independent predictor of treatment failure adjusted odds ratio=2.80; (95% CI, 1.26-6.22; P=.01).

Duong et al Annals of Emerg Med 2010

A double-blind, placebo controlled RCT of 161 pediatric patients with cutaneous abscesses. Patients were randomized to receive 10 days of placebo or trimethoprim-sulfamethoxazole after I&D. The follow up was either a visit or phone call at 10-14 days and then a call 90 days. The primary outcome was treatment failure, with new lesions at 10 and 90 days serving as the secondary outcomes. The threshold for non-inferiority was set at <7%. Per the authors, the failure rates were 5.3% (n=4/76) and 4.1% (n=3/73) in the placebo and antibiotic groups, respectively, difference 1.2%, (95% CI -infinity to 6.8%). They saw new lesions at 10-days in 26.4% of placebo and 12.9% of the ™P-SMX group, difference 13.5%, (95% CI -infinity to 24.3%). At 90 days 28.8% of placebo and 28.3%of the antibiotic group had new lesions, difference 0.5%, (95% CI -infinity to 15.6%). They thus concluded that although a short term decrease in the formation of new lesions may be seen antibiotics were not required for resolution in most pediatric skin abscesses after I&D.


So, as you can see the evidence is not 100% convincing either way, but it seems that treatment failure rates are not appreciably different with or without antibiotics. This obviously doesn’t completely answer the question, and certainly there are some situations where antibiotics are more likely to be beneficial than others. Let’s therefore turn our attention to the 2010 Infectious Diseases Society of America’s (IDSA) practice guideline for skin and soft tissue infections and the IDSA’s 2014 Update. Here’s what the panel of experts recommended:

Incision and drainage is the primary treatment for cutaneous abscesses

Antibiotics are recommended for:

  • Severe or extensive disease (multiple sites of infection, size greater than 5 cm)
  • Rapid progression in presence of associated cellulitis
  • Signs and symptoms of systemic illness (fever, ill appearance)
  • Associated comorbidities or immunosuppression (diabetes, cancer, lupus – the list goes on and on, use your judgement)
  • Extremes of age (especially babies under 6 months of age, and probably 12 months)
  • Body location of abscess makes drainage difficult (face, hand, and genitalia)
  • Associated septic phlebitis
  • Lack of response to incision and drainage alone

Treat purulent cellulitis (cellulitis draining pus, but without a drainable abscess) with a MRSA appropriate antibiotic for 5-10 days

Empiric MRSA coverage should take local resistance patterns into account, and could include:

  • Clindamycin
  • Trimethoprim-sulfamethoxazole
  • Tetracyclines (doxycycline or minocycline)
  • Linezolid

Get a wound culture if:

  • The patient is already on, or you will place them on antibiotic therapy
  • There are signs of severe local infection
  • Signs of systemic illness
  • The patient has not responded adequately to initial treatment
  • There is a concern for a cluster or outbreak

Now let’s take a look at what you might do if you encountered a few common scenarios, including what I’d recommend you discuss with patients and families.


The patient is not yet on antibiotics, you just performed an I&D

Have a discussion with the family about whether or not the child truly needs antibiotics. Use your time wisely and explain what an abscess is and why a walled-off collection of pus is inaccessible to antibiotics. If the child has any of the following you should choose a MRSA active drug while simultaneously considering local resistance patterns:

  • The abscess itself is >5 cm
  • Multiple lesions
  • Extensive surrounding cellulitis
  • Associated comorbidities or immunosuppression
  • Systemic signs of infection (fever due to the skin infection alone)
  • Body location making I&D more challenging/risky (face, genitals, hands/fingers)

Already started on antibiotics by another provider, you just performed an I&D

It is quite possible that the TMP-SMX that they are on helped treat the initial cellulitis and that you are now left with an abscess. It is also possible that they didn’t need them in the first place. in the (common) scenario that the child has already been started on antibiotics, especially if it is more than 2-3 days, I would recommend continuing them barring signs of allergy or other reaction.

Not yet an abscess but probably will be in 2-3 days

Start antibiotics if the patient has cellulitis. Talk to the parents about what an abscess is and how and why they form. Spend time helping parents recognize the signs and symptoms of an abscess and arrange for optimal follow up. Give the primary doctor a call and let them know how likely you think it is that a drainable abscess may form. They can then appropriately manage, or send the patient back to the ED if needed. If the lesion is very small and spontaneously draining you can recommend warm compresses an conservative treatment alone.

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Learn about the #FOAMed movement at the AAP NCE in San Diego

If you’ll be attending the annual National Conference & Exhibition in San Diego this weekend stop by and see me as I present a poster discussing the #FOAMed movement in Emergency Medicine. You can also learn about:

  • The difference between “stock” and “flow” and how these concepts relate to content on the web
  • The growth of Emergency Medicine educational websites
  • My efforts to create a consistent and robust online educational platform
You can come meet me on Friday, October 10 between 11AM and 12PM at the American Academy of Pediatrics Section on Emergency Medicine’s special Poster session at the Marriott Marquis in San Diego in Ballroom B.

I hope to see you there!

AAP Poster

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