A podcast on community acquired pneumonia

Fever, tachypnea and rales – it must be a community acquired pneumonia… right? Learn more about the diagnosis and management of this common problem in the Pediatric Emergency Department in this episode of PEM Currents.

You can check it out on Apple Podcasts or listen right here on PEMBlog.


Essential Reading

Bradley JS, Byington CL, Shah SS, Alverson B, Carter ER, Harrison C, Kaplan SL, Mace SE, McCracken GH Jr, Moore MR, St Peter SD, Stockwell JA, Swanson JT; Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Executive summary: the management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis. 2011 Oct;53(7):617-30. PMID: 21890766.

2017 AAP NCE: Highlights from the SOEM Abstracts Part 02

Kathleen M. Adelgais, MD, MPH et. al.

A Randomized Double Blind Trial of a Needle-free Injection System to Topical Anesthesia for Infant Lumbar Puncture

  • LPs are more likely to be successful if you use local anesthetic
  • The J-Tip – needle free injection – has onset of 1-2 minutes and doesn’t hurt. They compared this to topical anesthetic (EMLA)
  • Primary outcome was a neonatal pain score – LP success was a secondary outcome
  • Randomized controlled trial showed no difference between groups at 5 minutes
  • J-Tip had higher success rate OR = 2.9 (95% CI = 1-9.2)

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How to succeed on your next Lumbar Puncture

Why we do what we do: Early stylet removal in lumbar puncture

Paul C. Mullan, MD, MPH et. al.

A quality improvement project to decrease blood culture contaminants in a pediatric emergency department: an interrupted time series analysis

  • The national blood culture contaminant rate benchmark is <2%
  • The group used PDSA cycles to reduce contaminant rates from 3% that they were seeing locally to 1.51%
  • Secondary aim reduce blood culture ordering rare by 10% over 24 months
  • They excluded patients with cancer, central lines, VP shunts, neutropenia or transplant history
  • Key Drivers were  – increase venipuncture sterility
    • Nurse education initiatives including annual reviews, educational
  • …and reduce number of blood culture orders
    • With educational initiatives and guidelines as well as shared accountability
  • They are currently measuring ED bounce back rates – they have saved up to $290,000+
  • This study was nurse initiated!

Jay Pershad, MD, MMM, FAAP et. al.

Optimal Imaging Strategy for Suspected Acute Cranial Shunt Failure: A Cost-Effectiveness Analysis

  • The team did a cost effectiveness analysis (a model – not an actual comparative trial) of 4 modalities – note that all got plain X-Ray shunt series
    • CT
    • fast MRI
    • POCUS (point of care ultrasound) followed by CT
    • POCUS screening of optic nerve sheath diameter (ONSD) followed by MRI
  • If the rate of shunt failure is 30%, then POCUS + normal shunt series was the most cost effective
  • If there was an abnormal shunt series or ONSD on U/S then fast MRI was more cost effective when compared with CT
  • If they did fast MRI on all patients it would cost ~$270,000 to gain one additional QALY for a child with a shunt
  • In conclusion – children with low pre-test probability benefit most from U/S measurement of ONSD as the preferred initial test.
  • In children with high-pre-test probability the fast MRI is the most cost effective

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A podcast on CSF shunt complications

Jianling Xie et. al.

Relationship between Enteric Pathogen and Acute Gastroenteritis Disease Severity: A Prospective Cohort Study

  • Does it really matter which pathogen causes acute gastroenteritis?
  • They performed a perspective cohort of children with AGE and tested for 28 pathogens
  • They used the Total Modified Vesikari Scale
  • 36% had isolated vomiting in their cohort
  • Rotavirus, Norovirus and Adenovirus were the most common pathogens
  • Predictors of severe disease included
    • Rotavirus OR = 8
    • Salmonella OR = 5.4
    • Adenovirus OR = 2.1
    • Norovirus G2 OR = 1.8

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Validation of the Total Modified Vesikari Scale – Schnadower et al.J Pediatrician’s Gastroenterol Nutr, 2014

Fran Balamuth, MD, PhD, MSCE et. al.

Predictive Modeling for Organ Dysfunction in Children with Suspected Sepsis in the Emergency Department

  • A single-center prospective study where patients were treated with a sepsis protocol in the ED
  • They assessed for organ dysfunction by international consensus criteria – within the first 3 days of hospitalization
  • Their final model – bolstered by machine learning – showed that the following were associated with organ dysfunction
    • WBC
    • Procalcitonin
    • Time to initial IV antibiotics
    • Time to initial IV fluids
  • Their machine learning algorithm had the following test characteristics – in the validation set. Note that these values were higher in the “Training” set, where they actually built the model.
    • Sensitivity 83%
    • Specificity 63.%
    • Positive Likelihood Ratio 90%
    • Negative Predictive Value 49.4%

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Are you pro Procalcitonin?

David Piechota, MD et. al.

Refinement of Appendix Ultrasound Interpretation to Limit Equivocal Results

  • The team begun using a standardized assessment tool for appendicitis ultrasound
  • Most common secondary signs associated with appendicitis when the appendix was not seen include
    • Non-compressible appendix
    • Echogenic fat
    • RLQ tenderness
  • If >1 secondary sign was seen rate of apps was 30.2% versus 6.5% if none were seen
  • Though rate of actually finding the appendix didn’t change they were better able to attend to the nuances of  ultrasound interpretation

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2017 Starter Pack: Appendicitis

Rohit P. Shenoi, MD et. al.

The Pediatric Submersion Score Predicts Children at Low Risk for Injury Following Submersions

  • A single center cross-sectional derivation and validation study to predict children at low risk for injury after a submersion event
  • To predict safe discharge at 8 hours the score identified 5 factors – a higher score is better
    • Normal mental status
    • Normal respiratory rate
    • Absence of dyspnea
    • Absence of need for respiratory support (intubation, bag valve mask, CPAP)
    • Absence of hypotension
  • The overall discriminate ability peaks at 75% (score 3.5)
  • A score >4 predicts safe discharge home from the ED at 8 hours