Bronchiolitis! The Complete 8-Part Series Updated for 2014

I recently made some updates to my 8-part Bronchiolitis! series – specifically in the albuterol and racemic epinephrine posts. You can check out the entire series via the links below. I also highly recommend you read the AAP’s Clinical Practice Guideline on bronchiolitis as well.

The full pdf is FREE and available here

Here are all eight posts in the series.

I: Let’s just get our definitions straight all right?

II: I’ll huff and I’ll puff and… Albuterol won’t make a difference (probably)

III: Race on over and get your adrenaline pumping (with this nebulized treatment)

IV: Should salty saline stop symptoms?

V: Roid rage!

VI: Testing 1-2-3 Testing?

VII: Hey PEEPs! Let’s talk respiratory support

VIII: Bringing ‘em all home (or into the hospital)

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Minor TBI and vomiting alone? Should we be worried?

Next up from the top ten articles presented at the recent AAP NCE in San Diego is a secondary analysis from the PECARN head injury study published in Lancet in 2009. I’m sure that most have you have seen a child who hit their head with vomiting as their only symptom. The authors compared children with isolated vomiting versus those with vomiting and something else. That something else is further elaborated by the following “extensive definition:”

Patient less than 18 years old with:

  • No history of LOC
  • GCS/Pediatric GCS score of 15
  • No signs of altered consciousness (eg, sleepiness, agitation)
  • No palpable skull fracture or signs of basilar skull fracture
  • Acting normally per parent/guardian
  • No scalp hematoma or other traumatic scalp finding (eg, abrasion or laceration)
  • No headache (for patients 2–18 y)
  • No seizure after the head trauma
  • No neurologic deficits (eg, motor or sensory abnormalities)
  • No amnesia (for patients 2–18 y)

The two outcomes of the study were:

Clinically important traumatic brain injury (ciTBI)

  • Death
  • Neurosurgical procedure
  • Intubation for at least 24 hours
  • Hospitalization for 2 or more nights because of the head trauma in association with TBI on cranial CT

Traumatic brain injury on CT, defined as “any acute traumatic intracranial finding or a skull fracture depressed by at least the width of the skull.”

Association of traumatic brain injuries with vomiting in children with blunt head trauma

Dayan PS, Holmes JF, Atabaki S, Hoyle J Jr, Tunik MG, Lichenstein R, Alpern E, Miskin M, Kuppermann N; Traumatic Brain Injury Study Group of the Pediatric Emergency Care Applied Research Network (PECARN). Annals of Emergency Medicine, 2014

Links PubMed Annals of Emergency Medicine

The bottom line

The risk of TBI in children with head injury and isolated vomiting is very low, and thus many children can be observed in lieu of obtaining a head CT

What they did

The authors performed a secondary analysis of the original 42,112 patients in the original Lancet study and compared 815 patients with isolated vomiting and 4,577 patients with non-isolated vomiting. They found:

  • ciTBI in 2/815 (0.2%; 95% CI 0% to 0.9%) in the isolated vomiting group versus 114 of 4,577 (2.5%; 95% CI 2.1% to 3.0%) with nonisolated vomiting (difference -2.3%, 95% CI -2.8% to -1.5%)
  • Noting that many patients diddid get a CT, they found “garden variety” TBI on CT in 5 of 298 (1.7%; 95% CI 0.5% to 3.9%) with isolated vomiting versus 211 of 3,284 (6.4%; 95% CI 5.6% to 7.3%) with nonisolated vomiting (difference -4.7%; 95% CI -6.0% to -2.4%)
  • No significant independent associations between prevalence of either outcome with respect to timing of vomiting or proximity to last episode of vomiting

What you can do

  • Do a thorough H&P and assess for all of the items on the extensive definition lis
  • Use those to help you determine if the child has isolated vomiting or if there is something else
  • If there are other concerning findings the risk of ciTBI is 2.5% versus 0.2% – so you should strongly consider ordering a head CT
  • If the child has isolated vomiting consider observation in the ED – the length of that observation os dependent on the child and your and the parents’ comfort. Note that blood accumulating inside the skull will generally do bad things within 4-6 hours in the cranium with closed sutures.

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What are you waiting for? Send that kid with intussusception home

Back into the fray once more we go – or should I say back into the colon goes the ileum… Yes, the third article in the top 10 from the 2014 AAP NCE focuses on intussusception. Back when I was an intern™ after a child was reduced with air contrast enema they were subsequently admitted for 24 hours to the surgery service. Now, we discharge them home form the ED after a much shorter period of observation. Why? Well, you know where this is going. Let’s take a look at Gray et al. from the July 2014 edition of PEDIATRICS.

Recurrence rates after intussusception enema reduction: a meta-analysis

Gray MP, Li SH, Hoffmann RG, Gorelick MH. PEDIATRICS, 2014

Links PubMed PEDIATRICS

The bottom line

The risk of recurrence within 48 hours after successful air contrast enema reduction is low for well appearing children – therefore, consider discharging them home form the ED

What they did

The authors queried PubMed, Cochrane and OVID in an effort to determine the recurrence rate for intussusception after successful reduction. They reviewed 69 studies of children 0 to 18 years that had radiographically proven intussusception reduced by enema and the number of recurrences. To assure validity 10% of the records were reviewed by a second author. There was considerable variability amongst the 69 reviewed studies, with few detailing timing of recurrences exactly. Their analysis was also limited by the fact that most studies on intussusception are retrospective given its relative rarity. Note that the original article’s abstract has an error – the correct values are in the text. This is pointed out in the following errata. A few abbreviations are used: CE contrast enema, UGNCE ultrasound-guided non contrast enema, FGAE fluoroscopy-guided air enema

Ultimately they noted the following:

  • Overall recurrence rates
    • CE 12.7% (95% CI: 11.1%–14.4%, I2 = 28.8%)
    • UGNCE 7.5% (95% CI: 5.7%–9.8%, I2 = 52.4%)
    • FGAE 8.5% (95% CI: 6.9%–10.4%, I2 = 50.1%)
  • Recurrence rates within 24 hours
    • CE 3.9% (95% CI: 2.2%–6.7%, I2 = 47.0%)
    • UGNCE 3.9% (95% CI: 1.5%–10.1%, I2 = 0.0%)
    • FGCE 2.2% (95% CI: 0.7%–6.5%, I2 = 59.8%)
  • Recurrence rates within 48 hours
    • CE 5.4% (95% CI 3.7%–7.8%, I2 = 32.3%)
    • UGNCE 6.6% (95% CI: 4.0%–10.7%, I2 = 0.0%)
    • FGAE 2.7% (95% CI: 1.2%–6.5%, I2 = 73.8%)

What you can do

  • You can safely discharge a well-appearing patient to home after successful intussusception reduction regardless of technique
  • Recognize, and teach that he risk of recurrence in the first 24 hours post reduction is low; 2.2-3.9%
  • Even if you take the 24 hour risk to be the highest value of 3.9%, you would need to hospitalize 26 patients for 24 hours to see a single recurrence
  • Know that serious post-reduction complications are rare
  • Remember that any child that can’t be reduced needs a surgeon

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

There are numerous techniques that we can use to improve our likelihood of success in performing a lumbar puncture. There is one that has a bit of nuance to it that I thought would be an excellent theme for my latest Why We Do What We Do post. So, without further ado, let’s talk about early stylet removal. I’m also partial to it given that it has been nicknamed “The Cincinnati Method” (even though it was well before my time). The original citation FYI – Bonadio WA. Interpreting the traumatic lumbar puncture. Contemp Pediatr Res Q. 1992;1:23–32. Good luck finding a pdf.

How does one actually perform it?

  • Insert the spinal needle with the stylet in place
  • Advance completely past the epidermis and dermis (<1cm in most children)
  • Remove the stylet
  • Advance forward until reflux of CSF noted
  • Reinsert the stylet and withdraw the needle

You can watch the technique in action during this brief video I made for the AAP’s PediaLink service (courtesy of AAP PediaLink)

Why does it help?

In short, you avoid overshooting the subarachnoid space and hitting the vascular plexus of the ventral epidural space. Interestingly, you can measure the depth to the subarachnoid space if you’re interested by using the following calculation:

Depth of LP = 0.77cm + (2:56 × BSA [in meters squared])

I think this diagram is most helpful in showing why early stylet removal is potentially beneficial.

Early Stylet Removal diagram.001

As you can see in the diagram above, with the stylet still in place if you enter in the midline perpendicular to the CSF target you have the maximum space from which to get fluid. But, if your angle of entry is slightly off (only a few degrees will do it) you can see that the angle becomes more magnified. Using early stylet removal will allow you to see reflux of fluid into the spinal needle the instant you enter the space, thus giving you confirmation before you “back wall” the needle into a venous plexus.

Are there any risks?

Those of us who have been performing LPs for a loooong time may recall an epoch where butterfly needles were used to perform LPs. Those procedures left patients at risk for intraspinal epidermoid tumors – late appearing intraspinal masses after an unstyleted needle pushing epidermal cells into the intraspinal space. These can create a mass effect. See this case series from a while back for more information on how they presented. Fortunately, the use of styleted needles mitigated this risk. Theoretically the early stylet removal technique could cause the same risks if the stylet was removed before passing through the dermis – fortunately the best practice technique specifies that you should not remove the stylet until you have passed through the epidermis and dermis. There is no evidence – case series or otherwise –

What’s the evidence?

You wouldn’t want me to recommend something without supporting evidence would you? Well, in 2006 Baxter et al. published their findings of a prospective observational study in PEDIATRICS. They reviewed 428/594 (72%) infant LPs  – 377 of which were performed by trainees. Seventy-four percent (279/377) of the trainee LPs were successful. Amongst other factors local anesthesia was used for 280 (74%), and 225 (60%) were performed with early stylet removal. They found the following;

  • LPs were more likely to be successful in infants >12 weeks of age – OR=3.1 (95% CI 1.2-8.5)
  • Local anesthetic use showed increased odds of success OR=2.2 (95% CI 1.04-4.6)
  • In infants ≤12 weeks of age, early stylet removal improved success rates – OR=2.4 (95% CI 1.1-5.2)
  • Position (upright vs side-lying), drape use, and year of training were not significant predictors of success

So, as you can see – there is evidence and it stands firmly in the camp of those patients under the age of 12 weeks. However, that being said, I use this technique no matter the age of the patient. I do think that this is an example of where understanding a little bit more about why a certain technique is used will make a difference. This also applies to use of local anesthetics – maybe I’ll tackle that one in the future.

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Interosseous Needle Insertion using the EZ-IO

We do some hand-on practice from time to time during our Pediatric Emergency Medicine education sessions. Today we discussed and practiced using the EZ-IO for interosseous needle insertion. For those of you who weren’t able to be in chilly Cincinnati, OH here’s a video that we put together a little while back.

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Equivocal ultrasound for appy? Consider MRI instead of CT

Let’s move on to the next in the series of top ten articles presented at the 2014 AAP NCE in San Diego. Again, I’ll review the article and briefly and highlight how you can use the results in the ED.

By now, most of us have acknowledged that ultrasound is a fantastic imaging modality for the diagnosis of acute appendicitis. It is not, however the most sensitive and specific imaging test. That honor has gone to CT for many years running. MRI is here to challenge CT’s dynastic reign. MRI? But aren’t those expensive and impossible to get? A study published last April in PEDIATRICS would beg to differ.

Ultrasonography/MRI versus CT for diagnosing appendicitis

Aspelund G, Fingeret A, Gross E, Kessler D, Keung C, Thirumoorthi A, Oh PS, Behr G, Chen S, Lampl B, Middlesworth W, Kandel J, Ruzal-Shapiro C. PEDIATRICS, 2014

Links PubMed PEDIATRICS

The bottom line

In children with suspected acute appendicitis and an inconclusive ultrasound MRI is comparable to CT as follow up imaging

What they did

The authors retrospectively reviewed 662 patients that were evaluated for appy between 2008 and 2012. CT was used before 2010 (265 patients – 136 [51%] with positive appy), with ultrasound then MRI for confirmation thereafter (397 patients – 161 [41%] with positive appy). Data collected included time from triage to imaging and treatment and results of imaging and pathology. Ultimately they noted the following:

  • No difference in complicated appendicitis (perforation)by operative findings CT 32 (27.1%) vs US/MRI 33 (22.4%), p=0.4 or in pathology CT 17 (14.4%) vs US/MRI 18 (12.2%), p=0.7
  • No difference in negative appendectomy rate (on pathology) CT 3 (2.5%) vs US/MRI 2 (1.4%), p=0.7
  • Time to antibiotics did not differ CT 4.4 hours vs US/MRI 5.5 hours, p=0.07
  • Time to antibiotics did not differ CT 8.7 hours vs US/MRI 8.2 hours, p=0.14
  • Time to OR did not differ CT 13.2 hours vs US/MRI 13.9 hours, p=0.41
  • Hospital length of stay was similar between groups,  52.2 hours vs US/MRI 43.4 hours, p=0.18

In this study, the test characteristics of the imaging studies were as follows:

CT

  • Sensitivity 100% (95% CI, 97-100)
  • Specificity 98% (95% CI, 93-99)
  • PPV 98% (95% CI, 93-99)
  • NPV 100% (95% CI, 96-100)

Ultrasound/MRI

  • Sensitivity 100% (95% CI, 97-100)
  • Specificity 99% (95% CI, 97-100)
  • PPV 99% (95% CI, 95-100)
  • NPV 100% (95% CI, 98-100)

What you can do

  • You can consider ordering an MRI with contrast instead of a CT if you get an equivocal ultrasound for appendicitis as your diagnostic accuracy and time to important interventions may not differ
    • Obviously this is dependent on MRI availability, surgeon and radiologist availability and many more factors
  • Features considered diagnostic for ultrasound in appy include:
    • Noncompressible lumen
    • Diameter greater than 6-7 mm (98% sensitive)
    • Absence of gas in the lumen
    • Appendicolith
    • Thickened wall
    • Inflammatory changes surrounding the appendix may also be supportive
  • An equivocal ultrasound fails to show the appendix
  • Though not in the paper, know that MRI can actually be cheaper than CT
  • MRI also doesn’t expose patients to ionizing radiation

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